Pregnancy Questionnaire Template
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Complete Pregnancy Questionnaire Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1
2
3Patient Name:
DOB:
Age:
Date:
MM/DD/YY
YOUR FIRST VISIT
PREGNANCY QUESTIONNAIRE
Congratulations on your pregnancy. We designed this questionnaire for a few reasons. These questions will aid us in
completing your initial documentation, which must be completed before your initial visit. These intake questions will also
allow you the time to think about your family history or talk with your relatives about important family medical history or
other health factors that we would need to know about you. We are looking for diseases or disorders that can be passed
from one generation to the next. Because of our scheduling concerns, all information must be completed 72 hours
in advance of your appointment time. If you are unable to complete this form prior to your visit, we will be required
to reschedule your appointment. All blanks or questions must be answered even if you mark “0” (nothing or none)
or “N/A” (Not applicable). Thank you.
List any allergies to medications or foods:
Medication:
My reaction was:
Are you currently taking any medications? If yes, please list all of them:
Do You Have a Latex Allergy?
Is a Blood Transfusion Acceptable in an Emergency?
Do You Need an Anesthesia Consult?
DOB: mm/dd/yy
Age:
Race:
Marital Status:
Emergency Contact
Name:
Phone:
Occupation:
Education: (last grade completed)
Husband/Domestic Partner
Name:
Phone:
Language:
Ethnicity:
Father of Baby
Name:
Phone:
MENSTRUAL HISTORY
Hospital of Delivery:
Last Menstrual Period:
Period Monthly:
Frequency:
Newborn Care Provider:
❏ Definite
❏ Unknown
Age at First Period:
❏ Month Known
On Birth Control Pills at Conception:
Pre-
Height:
Pregnancy
Date of hCG (Home Pregnancy Test):
Weight:
❏ Normal Amount/Duration
LIST ALL PAST PREGNANCIES - INCLUDING: MISCARRIAGES, ABORTIONS, ECTOPICS, STILLBORNS
Date
Weeks
Length
Birth Weight
Sex
Type of
Epidural
Place of
Preterm
Comments/Complications
mm/dd/yy
Pregnant
of Labor
Delivery
Delivery
Labor
S U B U R B A N W O M E N ’ S H E A L T H S P E C I A L I S T S
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