Pregnancy Questionnaire Template

June 14, 2011

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]
Download Pregnancy Questionnaire Template in Word Format

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