Pregnancy Health Check | Pre-Pregnancy Questionnaire

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Questionnaire

Pre-Pregnancy Health

Pre-Pregnancy Health Questionnaire

Questionnaire

Fill out this questionnaire and submit your information to receive personalised advice and resources tailored to your unique journey.

Q1. Are you considering of planning pregnancy?

Q2. When are you considering pregnancy?

Q3. What age are you?

Q4. What is your weight?

Q5. What is your height?

Q6. Have you had a previous pregnancy? (If no, you can skip to Q9.)

Q7. Did you develop gestational diabetes during pregnancy?

Q8. Did you have any other medical conditions?

Q9. Do you have diabetes?

Q10. Are you currently taking any prescription medicines?

Q11. Are you taking folic acid?

Q12. Have you had a cervical screening test in the last 3 years?

Q13. Have you had 2 MMR (measles-mumps-rubella) vaccines in your lifetime?

Q14. Have you spoken to a Doctor, Nurse, Pharmacist, other Health Professional re your plans for pregnancy?

Q15. Do you smoke or vape?

Q16. If yes, how many times a day?

Q17. Do you drink alcohol?

Q18. If yes, how many units/drinks per week? (1 unit of alcohol is a single measure of spirits, half pint beer, small glass wine)

Q19. How often do you engage in physical activity that gets your heart rate up for 30 minutes or more per week? (e.g., brisk walking, swimming)

Q20. How many portions of fruit and vegetables do you eat per day? (A single portion is an apple, orange, banana or a handful of peas, carrots etc.)

Q21. Do you plan on breastfeeding your baby?

Q22. Are there other areas of interest, information, services, etc., that you would like us to consider providing before, during and following your pregnancy?

Q1. Are you considering of planning pregnancy?

Q2. When are you considering pregnancy?

Q3. What age are you?

Q4. What is your weight?

Q5. What is your height?

Q6. Have you had a previous pregnancy? (If no, you can skip to Q9.)

Q7. Did you develop gestational diabetes during pregnancy?

Q8. Did you have any other medical conditions?

Q9. Do you have diabetes?

Q10. Are you currently taking any prescription medicines?

Q11. Are you taking folic acid?

Q12. Have you had a cervical screening test in the last 3 years?

Q13. Have you had 2 MMR (measles-mumps-rubella) vaccines in your lifetime?

Q14. Have you spoken to a Doctor, Nurse, Pharmacist, other Health Professional re your plans for pregnancy?

Q15. Do you smoke or vape?

Q16. If yes, how many times a day?

Q17. Do you drink alcohol?

Q18. If yes, how many units/drinks per week? (1 unit of alcohol is a single measure of spirits, half pint beer, small glass wine)

Q19. How often do you engage in physical activity that gets your heart rate up for 30 minutes or more per week? (e.g., brisk walking, swimming)

Q20. How many portions of fruit and vegetables do you eat per day? (A single portion is an apple, orange, banana or a handful of peas, carrots etc.)

Q21. Do you plan on breastfeeding your baby?

Q22. Are there other areas of interest, information, services, etc., that you would like us to consider providing before, during and following your pregnancy?

Q1. Are you considering of planning pregnancy?

Q2. When are you considering pregnancy?

Q3. What age are you?

Q4. What is your weight?

Q5. What is your height?

Q6. Have you had a previous pregnancy? (If no, you can skip to Q9.)

Q7. Did you develop gestational diabetes during pregnancy?

Q8. Did you have any other medical conditions?

Q9. Do you have diabetes?

Q10. Are you currently taking any prescription medicines?

Q11. Are you taking folic acid?

Q12. Have you had a cervical screening test in the last 3 years?

Q13. Have you had 2 MMR (measles-mumps-rubella) vaccines in your lifetime?

Q14. Have you spoken to a Doctor, Nurse, Pharmacist, other Health Professional re your plans for pregnancy?

Q15. Do you smoke or vape?

Q16. If yes, how many times a day?

Q17. Do you drink alcohol?

Q18. If yes, how many units/drinks per week? (1 unit of alcohol is a single measure of spirits, half pint beer, small glass wine)

Q19. How often do you engage in physical activity that gets your heart rate up for 30 minutes or more per week? (e.g., brisk walking, swimming)

Q20. How many portions of fruit and vegetables do you eat per day? (A single portion is an apple, orange, banana or a handful of peas, carrots etc.)

Q21. Do you plan on breastfeeding your baby?

Q22. Are there other areas of interest, information, services, etc., that you would like us to consider providing before, during and following your pregnancy?

Expert Advice & Guidance For Preconception & Pregnancy Health

Email:

kathy@pregnancyhealthcheck.com

Phone:

+353 86 286 6149

PHC Guidance

Pre-Pregnancy PDF

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