Dati anagrafici e clinici
Cognome _____________________________ Nome _____________________ Data di nascita _____________
Luogo di nascita _______________Luogo di residenza ________________ Nazionalità_______________________
Titolo di studio [1] licenza media [2] licenza superiore [3] laurea [4] post-laurea
Professione_______________________________
Stato civile: [1] libera [2] Coniugata/convivente [3] In coppia ma non convivente
[4] Separata/Divorziata [5] Vedova Telefono_________________________
Dati relativi alla gravidanza attuale
Età gestazionale in settimane ________________ Data presunta del parto ______________________
Gravidanza [1] singola [2] gemellare Concepimento spontaneo [1] NO [2] SI
Procreazione Medicalmente Assistita [1] NO [2] SI Se sì Specificare [1] omologa [2] eterologa [1] ICSI [2] FIVET
[3]Maternità surrogata Se non è la prima gravidanza indica
A parte questa, quante gravidanze hai avuto?____________ Quanti figli hai?_________________
Come hai partorito? [1] Parto Spontaneo [2] Parto Spontaneo con analgesia [3] Cesareo
Indica il motivo
_______________________________________________________________________ ______
Hai vissuto un lutto postnatale?___________
Ci sono state interruzioni di gravidanza? [1] NO [2] SI Se sì, specifica ☐ Aborto Spontaneo n. ____________ Settimane gestazionali___________
Anno _________
☐ Interruzione Volontaria di gravidanza n.______ Settimane gestazionali___________ Anno _________
Diagnosi cliniche/Anamnesi personale e patologica (RISOLTE PRIMA della gravidanza) Prima della gravidanza:
Hai fatto interventi chirurgici? [1] NO [2] SI Se sì specifica cosa e anno___________________________
Hai avuto malattie? [1] NO [2] SI Se sì specifica cosa e anno___________________________
Hai sofferto di disturbi di ansia, depressione o altro? [1] NO [2] SI Se sì specifica cosa e anno_____________
Hai assunto farmaci? [1] NO [2] SI Se sì, specifica ________- _________________________________________
Malattie attuali
INSORTE PRIMA della gravidanza
Hai avuto malattie? [1] NO [2] SI Se sì specifica cosa e anno___________________________
Hai sofferto di disturbi di ansia, depressione o altro? [1] NO [2] SI Se sì specifica cosa e anno___________________________
Hai assunto farmaci? [1] NO [2] SI Se sì, specifica________- _________________________________________
INSORTE DURANTE la gravidanza Durante la gravidanza:
Hai fatto interventi chirurgici? [1] NO [2] SI Se sì specifica cosa __________________________________
Hai avuto malattie/disturbi? [1] NO [2] SI Se sì specifica cosa __________________________________
Hai sofferto di disturbi di ansia, depressione o altro? [1] NO [2] SI Se sì specifica _________________________
Hai assunto farmaci? [1] NO [2] SI Se sì, specifica ________- _________________________________________
Il tuo bambino soffre di qualche patologia? Se sì specifica ________________________________________
Parto
Come prevedi che partorirai? [1] Parto Spontaneo [2] Parto Spontaneo con analgesia [3] Cesareo
Perché questa
previsione?_____________________________________________________________ ___________
Come ti piacerebbe partorire? [1] Parto Spontaneo [2] Parto Spontaneo con analgesia [3] Cesareo
Indica il motivo
_______________________________________________________________________ __________
PAI - Le seguenti affermazioni descrivono pensieri, sentimenti e situazioni che le donne potrebbero provare durante la gravidanza. Siamo interessati alla tua esperienza in
Quasi mai
Qualche volta
quest’ultimo mese. Per cortesia, indica la risposta che meglio ti descrive
1 Mi chiedo come sia adesso il bambino
1 2 3 4
2 Mi immagino di chiamare per nome il bambino
1 2 3 4
3 Mi piace sentire il bambino che si muove
1 2 3 4
4 Penso che il bambino abbia già una sua personalità
1 2 3 4
5. Lascio che altre persone mettano le mani sulla pancia per sentire il bambino che si muove
1 2 3 4
6 So che il bambino risente delle cose che faccio
1 2 3 4
7 Progetto le cose che farò con il bambino
1 2 3 4
8 Dico agli altri quello che il bambino fa dentro di me
1 2 3 4
9 Immagino quale parte del bambino sto toccando
1 2 3 4
10 So quando il bambino dorme 1 2 3 4
11 Posso far muovere il bambino 1 2 3 4
12 Compro/faccio cose per il b. 1 2 3 4
13 Provo amore per il bambino 1 2 3 4
14 Provo a immaginare cosa il bambino stia facendo là dentro
1 2 3 4
15 Mi piace stare seduta con le braccia attorno alla pancia
1 2 3 4
16 Sogno il bambino 1 2 3 4
17 So perché il bambino si muove 1 2 3 4
18 Accarezzo il bambino attraverso la pancia
1 2 3 4
19 Condivido dei segreti con il bambino
1 2 3 4
20 So che il bambino mi sente 1 2 3 4
21 Sono molto emozionata quando penso al bambino
1 2 3 4
PRA-Q Indica per favore quanto spesso ti capita di provare questi sentimenti
Mai Raramen te Ogni Tanto Spess o S e
m p r e 1. Ho paura che il bambino possa avere un
handicap
mentale o soffrire di un danno cerebrale.
1 2 3 4 5
2. Ho paura che nostro figlio nasca morto, o che muoia durante immediatamente dopo il parto.
1 2 3 4 5
3. Ho paura che nostro figlio possa avere un difetto fisico o mi preoccupo che nel nostro bambino possa esserci qualcosa che non va a livello fisico.
1 2 3 4 5
4. Sono preoccupata per il dolore che proverò
durante le contrazioni e durante il parto. 1 2 3 4 5
5. Sono preoccupata per il fatto che non
riacquisterò la linea dopo il parto. 1 2 3 4 5
6. A volte penso che il nostro bambino possa essere
di salute cagionevole o che possa ammalarsi facilmente
1 2 3 4 5
7. Mi preoccupa il mio aspetto poco attraente 1 2 3 4 5 8. Provo ansia rispetto al parto perché
rappresenta un’esperienza che non ho mai provato prima
1 2 3 4 5
9. Sono preoccupata all’idea di non riuscire a controllare me stessa durante il travaglio e temo che urlerò.
1 2 3 4 5
10. Sono preoccupata del mio forte aumento
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