12-Week Prenatal Appointment Question List
Please complete this form prior to your 12-week prenatal appointment to help us provide the best care for you and your baby.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Appointment Date and Time
*
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Nausea or vomiting
Abdominal pain or cramping
Vaginal bleeding or spotting
Severe headaches
Fever
None of the above
Other
Are you currently taking any medications or supplements?
*
Yes
No
If yes, please list your current medications or supplements (name and dosage):
Do you have any allergies (medications, foods, environmental)?
*
Yes
No
If yes, please specify your allergies:
Have you had any previous pregnancies?
*
Yes
No
If yes, please provide details (number of pregnancies, outcomes, complications):
Do you smoke, use alcohol, or any recreational drugs?
*
Smoke
Alcohol
Recreational drugs
None
Family history of the following conditions (select all that apply):
*
Diabetes
High blood pressure
Genetic disorders
Birth defects
None of the above
Other
Do you have any specific concerns or questions you would like to discuss at your appointment?
Signature (please sign below)
*
Submit Appointment Form
Submit Appointment Form
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