Pregnancy Questionnaire

Pregnancy Questionnaire is prepared for women getting Pregnant for the first time. The main aim of these questions is to analyze and care to taken by mothers. Pregnancy Questionnaire intends to ask questions related to there health, baby growth, food to be taken and many more.

Pregnancy Questionnaire is must of both mother and father to answer. It’s just to bring some awareness in males on how to take care of there wife. A few short questions should be for father. The Questionnaire answered will be recorded by the medical centers and this will be utilized to check back if there is second Pregnancy.

Patient satisfaction questionnaire

Pregnancy Questionnaire should be made compulsory, as it makes both the doctors and patients life easier. There are also few straight forward questions which should be answered by every one. These questions could be like “have you every smoked or drank alcohol? One should never lie while answering these questions. You should also have good knowledge on your family’s medical history.

Sample Pregnancy Questionnaire

Name:
Age:
Phone number:
Fathers name:
Fathers mobile number:

Is this your first Pregnancy­­­­­­­­­­­­­­­­­­­?
Did you have any abortions?
Any miscarriages?
Do you have regular periods?
What is the weight of the baby?


What are you past and current health problems? Any thing like, liver disease, diabetes etcs
Did you have any surgeries from childhood?
Your immediate family members who have,
Alcoholism_____________________
Depression/suicide_______________
Prostate cancer_________________
Heart attack/stroke______________
High blood pressure_____________
Diabetes______________________
Dementia/Alzheimer’s____________
Colon cancer___________________
Thyroid cancer__________________


Do you drink alcohol or Smoke? If so how many times a week?
Kind for food you consume most?
GENETIC SCREENING?
Mother of Baby
Is your ancestry:
Asian
Hispanic
Italian, Greek,
Middle Eastern
French Canadian
African American
Jewish
Other_______________