Healthandnutrition Questionnaire - Pregnantwoman
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1
2Health and Nutrition Questionnaire
Pregnant Woman
Staff use only:
§ Weeks gestation:____________
Your name: ________________________Baby is due:_____________
§ Provider: __________________
§ Prenatal care:
Y N 49
At today’s visit, we will talk about:
Dental home:
Y N
¬ How are you feeling
¬ How much weight to gain
§ Shared Hgb value: Y N
¬ Healthy eating during pregnancy ¬ Questions you may have
§ Weight Gain pattern:
01 02 05 22
How are you feeling about this pregnancy? ________________________
When was your first doctor or midwife visit for this pregnancy?_________
§ Health/medical:
What was your weight before you became pregnant?________________
10 11 13 14 15 16 17 18 19
23 32 33 34 35 36 38 39 40
How much weight have you been advised to gain?__________________
41 43 50 51 52 53 59 60 61
62
Have you ever had or do you now have a health or medical condition
such as asthma, diabetes, depression, epilepsy, etc?
¨ No
¨ Yes If yes, please describe:_________________________
Do you take any of the following: (check all that apply)
¨ Prenatal vitamin
¨ Children’s vitamin
¨ Multi vitamin
¨ Iron
¨ Herbs or herbal remedies
¨ Medications:__________________
¨ None of these
__________________
What are your thoughts about breastfeeding?
§ Breastfeeding plan
¨ Good idea, I plan to exclusively breastfeed my baby
70
¨ Not sure, I would like more information
¨ I plan to both breastfeed and formula feed my baby
¨ I plan to feed my baby formula
Do you ever drink wine, beer or liquor?
Alcohol
¨ No
54
¨ Yes
§ 3 months prior to pregnancy:
¨ I would like to quit
_____days _____# drinks
What was the date of your last alcoholic drink?_____________________
§ Past month:
_____days _____# drinks
What best describes your smoking history?
¨ Never smoked
Smoking
¨ Smoked, but I quit on _____________ (month and year)
55 63
¨ Currently smoke: ____________# cigarettes per day
§ 3 months prior to pregnancy:
¨ I would like to quit
_____ # cigs per day
Does anyone else living in your household smoke inside the home?
¨ No
¨ Yes
Family environment:
90 96 97
Since you have been pregnant, have you taken any other drug(s) such as
meth, crack, cocaine or marijuana?
¨ No
56
¨ Yes
¨ I would like to quit
Over please…….
HNQ100 (1/08)
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