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

Pregnancy Questionnaire – 10 Practical Questions

1. How many weeks pregnant are you currently?
   ☐ Less than 12 weeks ☐ 12–20 weeks ☐ 21–28 weeks ☐ 29–36 weeks ☐ 37+ weeks

2. How would you describe your overall health during this pregnancy?
   ☐ Excellent ☐ Good ☐ Fair ☐ Poor

3. Have you been experiencing nausea or vomiting?
   ☐ Never ☐ Occasionally ☐ Often ☐ Daily

4. Are you getting enough rest and sleep?
   ☐ Yes ☐ Mostly ☐ Sometimes ☐ No

5. How would you rate your energy level during the day?
   ☐ Very high ☐ Good ☐ Low ☐ Very low

6. Are you currently experiencing any discomfort, such as back pain, swelling, or heartburn?
   ☐ None ☐ Mild ☐ Moderate ☐ Severe
   If yes, please describe: __________

7. Are you able to eat a balanced diet and drink enough fluids?
   ☐ Yes ☐ Mostly ☐ Sometimes ☐ No

8. Have you been attending your recommended prenatal checkups?
   ☐ Yes, regularly ☐ Sometimes ☐ Not yet ☐ No

9. Do you have any concerns about your pregnancy that you would like to discuss with your healthcare provider?
   ☐ No ☐ Yes
   If yes, please describe: __________

10. How confident do you feel about preparing for childbirth and caring for your baby?
    ☐ Very confident ☐ Somewhat confident ☐ Unsure ☐ Not confident

Note: This questionnaire is for general information and discussion with a healthcare professional; it does not diagnose or replace prenatal medical care.

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_______________