Prenatal Alcohol Exposure Assessment
Please complete this assessment to help us understand prenatal alcohol exposure risks and history.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Are you currently pregnant?
*
Yes
No
How many weeks pregnant are you? (If applicable)
How many pregnancies have you had (including current, if applicable)?
*
Did you consume alcohol during this pregnancy?
*
Yes
No
Prefer not to say
Alcohol Consumption Details
*
Rows
Frequency
Average Amount (drinks per occasion)
3 months before pregnancy
Never
Once or twice
Monthly
Weekly
Daily
0
1-2
3-4
5-6
7 or more
First trimester
Never
Once or twice
Monthly
Weekly
Daily
0
1-2
3-4
5-6
7 or more
Second trimester
Never
Once or twice
Monthly
Weekly
Daily
0
1-2
3-4
5-6
7 or more
Third trimester
Never
Once or twice
Monthly
Weekly
Daily
0
1-2
3-4
5-6
7 or more
What types of alcoholic beverages did you consume? (Select all that apply)
Beer
Wine
Spirits (e.g., vodka, whiskey)
Cocktails/Mixed drinks
Other
On a scale of 1 to 5, how aware were you of the risks of alcohol consumption during pregnancy?
*
Not aware
1
2
3
4
Very aware
5
1 is Not aware, 5 is Very aware
Have you received any counseling or information about alcohol use during pregnancy?
*
Yes, from a healthcare provider
Yes, from other sources
No
Please share any additional comments or relevant information about alcohol use and pregnancy.
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