I don't know how 'blogger' will publish this as an orderly single page form, but, it probably looks better on paper. It's good just to have it out here for conversation.
USING THE RATING SCALES LISTED WITH EACH CATEGORY. PLEASE RANK YOUR EXPERIENCE WITH PREGNANCY. ENCLOSED ARE TWO COPIES OF THE SURVEY. IT WOULD BE HELPFUL TO KNOW THE EXPERIENCE OF YOUR HUSBAND, PARTNER OR OTHER PARENT OF THE CHILD/CHILDREN. YOU MAY FILL IN THE SURVEYS, preferably separately or together. Kindly mail them back in the prepaid envelope provided. All information is confidential so please be as open and honest as you can. If you would like to know the results of the survey kindly list a return address, however, it will be approximately six months before the results will be tabulated and quantified.
When thinking about yourself and your recent pregnancy in general: Please rate your feelings below using the every descriptors available which applies when ever possible with the scale provided above. If you feel limited by the survey options for any category kindly respond in your own words.
1 2 3 4 5
Very slightly a little moderately quite a bit extremely
or not at all
Example:
l. The three months prior to becoming pregnant:
_____3____interested ___3____irritable
_____2___distressed ___2____alert
_____1___excited ___1____ashamed
Comments: I was not expecting to get married, yet alone pregnant. Life has always been good to me.
1. The three months prior to becoming pregnant:
_________interested ________irritable
_________distressed ________alert
_________excited ________ashamed
_________upset ________inspired
_________strong ________nervous
_________guilty ________determined
_________scared ________attentive
_________hostile ________jittery
_________enthusiastic ________active
_________proud ________afraid
Comments:__________________________________________________________________
___________________________________________________________________________
2. The first trimester of your pregnancy.
_________interested ________irritable
_________distressed ________alert
_________excited ________ashamed
_________upset ________inspired
_________strong ________nervous
_________guilty ________determined
_________scared ________attentive
_________hostile ________jittery
_________enthusiastic ________active
_________proud ________afraid
Comments:____________________________________________________________________
_____________________________________________________________________________
3. The second trimester of your pregnancy.
_________interested ________irritable
_________distressed ________alert
_________excited ________ashamed
_________upset ________inspired
_________strong ________nervous
_________guilty ________determined
_________scared ________attentive
_________hostile ________jittery
_________enthusiastic ________active
_________proud ________afraid
Comments:____________________________________________________________________
_____________________________________________________________________________
4. The third trimester of your pregnancy.
_________interested ________irritable
_________distressed ________alert
_________excited ________ashamed
_________upset ________inspired
_________strong ________nervous
_________guilty ________determined
_________scared ________attentive
_________hostile ________jittery
_________enthusiastic ________active
_________proud ________afraid
Comments:____________________________________________________________________
5. The first three months after the birth of your child/children.
_________interested ________irritable
_________distressed ________alert
_________excited ________ashamed
_________upset ________inspired
_________strong ________nervous
_________guilty ________determined
_________scared ________attentive
_________hostile ________jittery
_________enthusiastic ________active
_________proud ________afraid
Comments:____________________________________________________________________
6. The fourth through six months after birth of your child/children.
__________interested ________irritable
__________distressed ________alert
__________excited ________ashamed
__________upset ________inspired
__________strong ________nervous
__________guilty ________determined
__________scared ________attentive
__________hostile ________jittery
__________enthusiastic ________active
__________proud ________afraid
Comments:____________________________________________________________________
We sincerely appreciate your participation. It is the continued hopes of the survey authors to improve the lives of women, women who chose pregnancy and parents.
References to the Study:
Watson, David and Lee Anna Clark, Development and Validation of Brief Measures of Positive and Negative Affect: The PANAS Scales, Journal of Personality and Social Psychology, 1988, Vol. 54, No. 6, 1063-1070.
