Pregnancy Questionnaire Template
Pregnancy questionnaire template is a ready to use document, which is widely used in the nursing homes and hospitals to estimate the initial medical condition of a pregnant woman. A pregnant participant is asked to fill the questionnaire to provide sufficient information to conduct the further treatment or medicinal examination.
Sample Pregnancy Questionnaire Template:
Name: ___________________
Age: _________________ Blood Group: ____________________
Address: ______________________________________________
Email Address (if any):___________________________________ [all the details of the pregnant lady or the participant]
Kindly answer underneath mentioned questions by filling or choosing the right answer:
Q1: How did you conduct your pregnancy test and what outcome of the test indicated you that you are pregnant?
__________________________________ [This question helps to know the basic pregnancy knowledge of the pregnant lady]
Q2: Are you visiting any doctor for consulting your current medical condition?
- Yes
- No [this question helps to get an answer as to whether the lady is visiting any doctor or not ]
Q3: How many times in a month, you are recommended to visit our gynaecologist department?
- One in a month
- Twice in month
- Every week
- Not sure [the question is asked to know the frequency at which the lady is asked to visit doctor]
Q4: Please tell us which of the following symptoms you are feeling the most?
- Nausea
- Vomiting
- Achy legs
- Morning sickness
- Laziness [This question relates to the symptoms of pregnancy]
Q5: Are you allergic to any food? If yes please mention the details?
Q5: Kindly give us the details of your current monthly pregnancy status and the recommended treatments, if any?
____________________________________ [the participant will mention the medication and other details of her pregnancy]
Category: Health Questionnaire