Sample Pregnancy Questionnaire

Sample pregnancy questionnaires are filled by the women who are pregnant. In such a questionnaire, the knowledge of the participant is being examined by various pregnancy related questions which are based on pregnancy symptoms, general checkups and associated complications.

Sample Pregnancy Questionnaire:

Name: ____________________

Date of Birth: ________________ Age: ______________ blood group: ________________

Address: ___________________________

Phone Number: ____________________

Email id: _______________________________

Q1: Do you think you have the full knowledge of pregnancy periods and associated benefits?

• Yes

• No

• Not much

Q2: Is this a planned pregnancy?

• Yes

• No

Q2: How did you confirmed or checked that you are pregnant?

• Used a pregnancy strip to check

• Consulted a gynaecologist

• Calculated from certain physical symptoms

Q3: How often do you visit your gynaecologist?

• Once in a week once in a month

• Twice in a month

• Once in two months

• Whenever required

• Not visiting a doctor

Q3: Are you taking any prescribed pills and salts?

• Yes

• No

• Sometimes

• Never

Q4: How frequent are you feeling nausea, giddiness and other expected symptoms?

• Daily

• Sometimes

Q5. How are you controlling above mentioned symptoms of your pregnancy?

• Taking prescribed pills

• Using homemade remedies

• Not taking anything

Q6: Do you feel uncomfortable after taking certain medicines?

• Yes

• Sometimes

• No

Q7: Are you feeling some kind of weakness during the pregnancy?

• Yes

• No

Q8. Is there any other query which you would like to clarify regarding pregnancy?