Prenatal Visit Questionnaire

Prenatal Visit Questionnaire — Form Fields

This healthcare template includes 9 fields. Prenatal visit intake questionnaire for expecting mothers to document pregnancy history, current symptoms, and health concerns. Suitable for OB-GYN offices and midwifery practices. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Estimated Due Date (text, required)
• Current Week of Pregnancy (number, required)
• Number of Previous Pregnancies (number, required)
• Current Symptoms (select all that apply) (checkboxes, optional) — options: Nausea / vomiting, Fatigue, Swelling in hands or feet, Headaches, Back pain, Vaginal bleeding or spotting, None
• Are you currently taking prenatal vitamins? (multiple choice, required) — options: Yes, No
• Current Medications (long text, optional)
• Questions or Concerns for Your Provider (long text, optional)