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

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