Pregnancy Nutrition Questionnaire
Name
First Name
Last Name
Email
example@example.com
Phone number
DOB
How many weeks pregnant are you?
Are you carrying more than one baby?
Yes
No
If yes, how many?
Do you have other children?
Yes
No
If yes, how old are they?
What did you eat yesterday? (Breakfast, Lunch, dinner & snacks)
What did you drink yesterday? Please give amounts e.g. 3 cups of tea, 2 cans of cola etc.
How many times a week do you eat these foods?
Rows
Number
Red meat
Oily fish
Chicken
Eggs
Green vegetables
Fruit
Salad
Wholegrains (oats, brown rice, brown bread)
Dairy (yogurt, cheese, milk)
Do you follow a special diet e.g. vegetarian or vegan? (if yes, please give details below)
Do you take any supplements? (If yes, please give details below)
Do you have any allergies? (If yes, please give details below)
Do you have any health conditions? (If yes, please give details below)
Do you take any medications? (If yes, please provide name and dosage below)
What pregnancy symptom are you struggling with the most (Fatigue, nausea, constipation etc)? Please share how this is affecting you.
What are your favourite foods?
What are your least favourite foods?
On a scale of 1-10 (with 10 being very stressed and 1 being very relaxed), how stressed are you?
On a scale of 1-10 (with 10 being very happy and 1 being very low mood), how positive are you feeling?
Is there any time of day you really struggle to eat?
Is there anything else you'd like me to know or are worried about?
Submit
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