Preconception Planning Checklist
Assess your health and lifestyle as you prepare for pregnancy. This checklist helps you review important steps before conception.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Have you scheduled a preconception checkup with your healthcare provider?
*
Yes
No
Planning to schedule
Are you currently taking any prenatal vitamins or folic acid supplements?
*
Yes, daily
Occasionally
No
Have you reviewed your current medications with a healthcare professional?
*
Yes, all medications reviewed
Some medications reviewed
No
Have you received recommended vaccinations (such as rubella, varicella, flu, COVID-19)?
Rubella
Varicella (chickenpox)
Influenza (flu)
COVID-19
Other
Do you or your partner have any known genetic conditions or family history of inherited diseases?
Yes
No
Not sure
Lifestyle Factors
*
Rows
Yes
No
Sometimes
Do you smoke?
1
2
3
Do you consume alcohol?
4
5
6
Do you use recreational drugs?
7
8
9
Do you exercise regularly?
10
11
12
Do you follow a balanced diet?
13
14
15
How would you rate your current stress level?
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Are you currently managing any chronic health conditions (e.g., diabetes, hypertension, thyroid disorders)?
Yes
No
What are your main goals or concerns regarding preconception planning?
Would you like to be contacted by a healthcare professional for further guidance?
Yes, please contact me
No, thank you
Submit Checklist
Should be Empty: