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IAMH Postpartum Assessment Form
1.
Please list your email address
2.
What MS County do you live in?
3.
Does anyone smoke inside your home?
Yes
No
4.
Are you currently breastfeeding or bottle-feeding?
Breastfeeding
Bottle-feeding
Both
5.
Do you have concerns or questions about breastfeeding?
Yes
No
6.
Are you concerned that you may have postpartum depression and or anxiety?
Yes
No
7.
Are you aware of services provided by Women, Infants, and Children (WIC)?
Yes
No
8.
Are you aware of the services provided by Early Periodic Screening, Diagnostic, and Treatment (EPSDT)?
Yes
No
9.
Do you have a pediatrician for your baby?
Yes
No
10.
Do you have a medical provider for your primary care?
Yes
No
