1. Weight Changes During Pregnancy: What was your weight before pregnancy?

Has your
weight changed in the past year? How much weight have you gained since your last
menstrual period?

2. Fever or Chills: Have you experienced any fever or chills (excluding those from a cold)
since your last menstrual period?

3. Nasal Congestion and Nosebleeds: Have you had nasal congestion or nosebleeds more
frequently than usual since becoming pregnant?

4. Throat Issues and Cough: Are you experiencing any throat problems, a persistent cough,
or frequent chest infections?

5. Nausea, Vomiting, and Thirst: Have you had persistent nausea or vomiting? Have you
felt unusually thirsty?

6. Bowel Changes: Have you noticed any blood in your stool, changes in your bowel habits,
or difficulty having a bowel movement?

7. Burning Sensation During Urination: Do you experience a burning sensation when you
urinate?

8. Vaginal Bleeding, Fluid Leakage, or Discharge: Have you had any vaginal bleeding,
leakage of fluid, or vaginal discharge?

9. Loss of Appetite and Sleep Problems: Have you lost interest in eating or are you having
trouble sleeping?

10. Urinary Tract Infection Symptoms: Do you feel any burning when you urinate?

11. Vaginal Issues: Are you experiencing any vaginal bleeding, fluid leakage, or unusual
discharge?

12. Mental Health: Have you lost interest in eating or sleeping lately? Have you felt
depressed, anxious, or like crying for no reason? Have you ever received professional
counseling for mental health?

13. Breast Changes: Have you noticed any breast pain, lumps, or unusual fluid leakage?

14. Feeding Plans: Have you thought about how you'll feed your baby (breastfeeding or
bottle-feeding)?

15. Other Concerns: Are there any other health concerns you'd like to discuss?

Section 2: Personal Health History

1. Family History: Will the baby's father or other close relatives (e.g., cousins) be 35 or older
when the baby is born?

2. Pregnancy History: How many times have you been pregnant, starting with your first
pregnancy? For each pregnancy, please provide the following information:

- Delivery date

- Baby's sex, weight, and gestational age

- Any complications (e.g., pregnancy-induced hypertension, diabetes, bleeding, depression)

3. Neonatal Complications: Did your baby experience any health problems during the first
two weeks of life (such as jaundice or infection)?

4. Perinatal/Neonatal Losses: Have you experienced any loss of a baby during pregnancy
or in the first year of life? If so, please provide details.

5. Abortion History: Have you ever had an abortion (spontaneous or elective)? If so, please
provide details about the procedure and gestational age of the fetus.

4. Molar Pregnancy: Have you ever had a molar pregnancy (a rare type of pregnancy)?

5. Ectopic Pregnancy: Have you ever had a pregnancy outside of your uterus (an ectopic
pregnancy)?

6. Menstrual History: Describe your menstrual history: When was your last period? Are your
periods regular, and if not, how long are they typically? Have you had any unusual bleeding
or spotting?

7. Birth Control: What type of birth control have you used in the past? If you've used birth
control pills, when did you last take them?

8. Fertility Issues: Have you had trouble getting pregnant for over a year?

9. Reproductive History: Have you ever had any abnormal Pap smears, reproductive
surgeries, or STIs (sexually transmitted infections)? If so, please provide details, including
dates of diagnosis and treatment.

10. Vaginal Infections: Have you ever had any vaginal infections (like bacterial vaginosis or
yeast infections)? If so, when was the last infection, and what treatment did you receive?

11. Blood Type and Rh Factor: Do you know your blood type and Rh factor? If you're Rh
negative, do you know your partner's Rh factor?

12. Blood Transfusion: Have you ever had a blood transfusion? If so, why and when?

13. Major Medical Problems: Do you have a history of any significant health problems (such
as heart trouble, diabetes, lung problems, or kidney disease)?

Section 3: Medical and Family History

1. Blood Transfusion: Have you ever received a blood transfusion? If so, when and why?

2. Major Medical History: Do you have a history of any serious medical conditions (e.g.,
heart problems, diabetes, lung disease, tuberculosis, or mental health issues)? Have you
experienced any problems with your reproductive organs, nerves, or hearing? Do you have
diabetes?

3. Twins or Multiple Gestation: Have you ever had twins or multiples?

5. Hospitalizations and Surgeries: Have you ever been hospitalized or had surgery
(excluding those related to this pregnancy)? If so, when, why, and were the issues resolved?

6. Current Medications: Are you currently taking any medications (prescription or otherwise)?
If so, please list them, how long you've taken them, and why you started taking them. Have
you had your flu shot this year?

Section 4: Family History

1. Birth Defects in Family: Does anyone in your family have a history of birth defects (like
cleft lip/palate, clubfoot, or intellectual disability)? Are there any inherited diseases (like
cystic fibrosis or hemophilia) in your family? What is your ethnicity/racial background?

2. Cardiovascular or Heart Problems: Has anyone in your family (grandparents, parents,

3. Lung Problems, Diabetes, etc.: Has anyone in your family had lung problems, diabetes,
tuberculosis, or asthma?

4. Cancer: Has anyone in your family been diagnosed with cancer? If so, what type?

Section 5: Lifestyle and Health Practices

[Link] Consumption: Since you became pregnant, have you consumed any alcoholic
beverages?

2. Smoking Habits During Pregnancy: How many cigarettes do you smoke each day?

3. Substance Use During Pregnancy: Have you used cocaine, marijuana, speed, or any
other street drugs during this pregnancy?

4. Social Habits: Does anyone in your family consider your social habits to be a
problem? Do your social habits interfere with your daily life? Please explain.

5. Daily Food Intake and Diet: What is your typical daily food intake? Are you following
any special diets? Do you have any food allergies or restrictions? If so, what are they?

6. Consumption of Unpasteurized Dairy: Do you eat lunch meats or drink unpasteurized

7. Vitamin Supplements: Do you currently take any vitamin supplements? If so, which ones?

Section 6: Activity and Exercise

1. Daily Exercise: Do you exercise regularly? If so, what kind of exercise and for how long?
2. Exercise Impact on Previous Pregnancies: Did your usual activity level or exercise affect
your previous pregnancies? Please explain.

3. Heavy Lifting: Do you perform any heavy lifting (over 20 pounds) at work or at home?

4. Fatigue Levels: Do you feel tired easily? Do you need more than 8 hours of sleep per
night? Do you find everyday tasks (like errands or housework) tiring? Describe your typical
sleep patterns.

5. Rest Periods: Do you take frequent rest breaks? If so, how long are they?

Section 7: Toxic Exposure

1. Exposure to Chemicals or Radiation: Have you or your partner ever worked with
chemicals or radiation? Are you exposed to high levels of any toxic substances (like cigarette
smoke)?

2. Exposure to Cats: Do you own a cat? If so, are you exposed to cat litter or cat feces?

Section 8: Role and Relationships

1. Occupation: What is your job?

2. Daily Activities and Interactions: Describe a typical day for you—your activities and the
people you interact with.

3. Feelings About Pregnancy and Partner Involvement: How do you feel about this
pregnancy? How does your partner feel about the pregnancy? What level of involvement do
they plan to have (e.g., not involved, interested, supportive, primary caregiver)?

Section 8 (Continued): Role and Relationships

1. Support Systems: Who are the main people in your support network at home? Please list
their names, ages, and relationships to you. Are they aware of any health problems you
might have?

2. Siblings and Pregnancy: Do you have any siblings? What are their reactions to this
pregnancy? Do you plan to involve them in any educational programs to help them adjust to
the new baby?

3. Domestic Violence: Has anyone ever threatened or harmed you? Has anyone ever forced
you to have sex?

4. Partner's Background: What is your partner's highest level of education and their job?
Does your partner use alcohol, tobacco, or illicit drugs? If so, how much and how often?