Online Pregnancy Questionnaire

An online pregnancy questionnaire is the most convenient way to understand and evaluate the pregnancy status. One can fill such a questionnaire by visiting an online website and the questionnaire is based on the initial pregnancy conditions, symptoms, current physical changes and other such details.

Sample Online Pregnancy Questionnaire:

Name of the participant: _________________

Date of birth: ____/____/_____, Age: _______

Blood Group:

E-mail Address: _______________________

Q1: Are you fully aware about the pregnancy symptoms and its initial tests?

  • Yes
  • No
  • Not fully aware

Q2: What was the last date of your periods?

Q3: Did you try to check or consult with the doctor regarding your pregnancy doubts?

  • Yes
  • No

Q4: Which of the following symptoms you are feeling?

  • Tenderness in beasts
  • Morning bed sickness
  • Vomiting sensation
  • Body ache after nausea

Q5: Which of the above given pregnancy symptoms you are encountering the most?


Q6: Did you get any recent bleeding or spotting after missing your periods along with facing the above mentioned symptoms?

  • Yes
  • Yes. A little spotting
  • Not at all

Q7: Are you taking some kind of medicines or homemade remedy to control any of the above given symptoms?

  • Yes
  • No
  • If yes, provide the name of the medicines: _______________________

Q8:  Are you prone to some allergies?

  • If Yes, give details _____________
  • No

Q9: Have you conceived before?

  • Yes
  • No

Q10. If answer to the above question is yes, how many children do you have at present?

Q11: Is this pregnancy planned?

  • Yes
  • No

Category: Health Questionnaire

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