Pregnancy Questionnaire

Pregnancy Questionnaire
Patient Name

First Name Last Name
Today's Date

Month Day Year
Date
Email
example@example.com
Phone Number

Area Code Phone Number
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PREVIOUS BIRTH EXPERIENCE
Is this your first pregnancy? (Yes/No) If not, please tell us about your previous pregnancy and/or birth experience(s).
Do you plan to follow the same plan as your previous delivery? (Yes/No) If no, what would you like to change?
CONCEPTION & EARLY PREGNANCY
When is your expected or calculated due date?

Month Day Year
Date
Did you have any difficulty conceiving? (Yes/No) If yes, please explain:
Have you ever used any form of hormonal or oral contraceptives? (Yes/No) If yes, which ones and for how long?
When was your last menstrual cycle?
Date
What was your pre-pregnancy weight?
lbs
Current weight?
lbs
Have you experienced morning sickness? (Yes/No) If yes, please explain:
CURRENT HEALTH CONDITIONS
What type of exercises are you currently performing?
Please tell us about your current diet, what you eat daily, and any dietary restrictions.
Have you taken any medications or supplements during your pregnancy? (Yes/No) If so, what type and which brand?
Have you had any slips, falls, or any other physical trauma during the pregnancy? (Yes/No) If yes, please explain:
Have you had any major emotional stressors during your pregnancy? (Yes/No) If yes, please explain: