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Pregnancy Health Consultation Questionnaire

This form helps us understand your pregnancy health, nutrition, and lifestyle to provide personalized guidance. All information shared will remain confidential.

Contact us

First name*

Last name

Age*

Email*

Phone*

Profession / Occupation*

Location*

Height*

Weight*

Pre-pregnancy Weight (kg) – if known*

Current Pregnancy Week (Gestational Age)*

Expected Due Date (EDD)*

Is this your first pregnancy?*

Yes

No

If No, please select previous pregnancy outcome(s)*

C-section

Miscarriage

Preterm delivery

Stillbirth

Not applicable

Do you have any of the following medical conditions?*

Gestational diabetes

Type 1 / Type 2 diabetes

Thyroid disorder

PCOS

High blood pressure

Anemia

Asthma

Heart condition

None

Any past surgery or hospitalization?*

Currently taking any medications or supplements?*

Which symptoms are you currently experiencing?*

Nausea / vomiting

Acidity / heartburn

Constipation

Back pain

Leg cramps

Swelling (feet / face)

Fatigue

Mood swings

None

Any bleeding, spotting, or severe pain?*

Yes

No

Diet type*

How many meals do you eat in a day?*

Daily water intake (approx.)*

Any food cravings or aversions?*

Tea / Coffee intake per day*

None

1 cup

2 cups

More than 2 cups

Do you smoke or consume alcohol?*

No

Yes (before pregnancy)

Yes (currently)

Do you currently exercise?*

Walking

Prenatal yoga

Physiotherapy exercises

Household activity only

No exercise

Any pain or difficulty during movement?*

Average sleep duration*

Less than 6 hours

6–8 hours

More than 8 hours

Sleep quality*

Good

Disturbed

Very poor

Current stress level *

1

2

3

4

5

1 = Very low, 5 = Very high

Feeling anxious, low, or emotionally overwhelmed?*

Yes

No

Sometimes

Recent blood reports available? (Hb, Sugar, TSH, etc.)*

Yes

No

Any doctor-advised restrictions or special instructions? *

What is your main concern right now?*

Healthy weight gain

Blood sugar control

Anemia

Digestion issues

Pain management

Stress / anxiety

General pregnancy nutrition

What do you expect from this consultation?*

I confirm that the information provided is accurate to the best of my knowledge.

by Nausheen Zeri

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