Pregnancy Caffeine Intake Assessment Form
Please complete this assessment to help us evaluate your caffeine intake during pregnancy. Your responses will assist in providing appropriate guidance and support.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How many weeks pregnant are you?
*
Which trimester are you currently in?
*
First Trimester (Weeks 1-13)
Second Trimester (Weeks 14-27)
Third Trimester (Weeks 28-42)
On average, how many servings of the following caffeinated products do you consume per day?
*
Rows
Number of Servings
Coffee
Tea
Soft Drinks (e.g., cola)
Energy Drinks
Chocolate
Other
How much caffeine (in mg) do you estimate you consume daily? (If unsure, please provide your best estimate)
*
Are you aware of the recommended daily caffeine limit during pregnancy?
*
Yes
No
Please rate your agreement with the following statements regarding caffeine intake during pregnancy.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I believe caffeine can affect pregnancy outcomes.
1
2
3
4
5
I have reduced my caffeine intake since becoming pregnant.
6
7
8
9
10
I find it difficult to avoid caffeinated products.
11
12
13
14
15
I have discussed caffeine intake with my healthcare provider.
16
17
18
19
20
Have you experienced any of the following symptoms since becoming pregnant? (Select all that apply)
Difficulty sleeping
Increased heart rate
Nausea
Anxiety
None of the above
Other
Do you plan to change your caffeine intake during the remainder of your pregnancy?
*
Yes, I plan to decrease it
Yes, I plan to increase it
No, I plan to keep it the same
Unsure
If you have any additional comments or concerns about caffeine intake during pregnancy, please share them below:
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