Teenage Pregnancy Questionnaire


Teenage pregnancy questionnaire is a set of questions designed to analyze the condition of girls who have become pregnant during their teenage years or are suspicious that they would become so. This questionnaire assesses their aptitude for early motherhood, sexual awareness and also child responsibility. These questionnaires are conducted by organizations which intend to promote sexual awareness among people, pediatricians, doctors, gynecologists etc.

Teenage Pregnancy Questionnaire Sample

Name:               __________________________________________________________________

Age:          __________________________________________________________________

Email:               ________________________        Phone:               ________________________

  1. At what age did you started being sexually active?
  2. How often did you take part in sexual activities? Did you ever face any problem in health?
  3. Did you have sex education at your school?
  4. Please tell us your level of awareness on the following. Write 0 if you do not have any knowledge, write 5 if you have substantial knowledge.
    1. Contraceptive pills
    2. Condoms
    3. STI and STDs
    4. Abortion
    5. Any other contraceptive method, please mention:        ________________________
    6. What is your education level?
      1. Passed  GED
      2. Studying for GED
      3. Studying in university or college
      4. Dropped out of school after  _________ th grade
      5. Dropped out of college after ________th year.
      6. If you have dropped out of school or college what were the reasons?

________________________________________________________________________________________________________________________________________________________________________________________________________________________

  1. Have you ever been a victim of sexual molestation? If yes did you complain to the police?

________________________________________________________________________________________________________________________________________________________________________________________________________________________

  1. You are at present living with:       _________________________________________
  1. Do you or your partner or have a source of income? Did you have any prior job trainings? How do you plan to raise your baby?

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Category: Health Questionnaire

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