Preconception Visit Checklist
Complete this form to provide your healthcare provider with important information prior to conception planning.
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
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any current or past medical conditions?
*
Diabetes
Hypertension
Thyroid disorders
Asthma
Seizure disorders
None of the above
Other
Are you currently taking any medications or supplements?
*
Yes
No
Please list all current medications and supplements.
Do you or your partner have a family history of genetic disorders or inherited conditions?
Yes
No
Not sure
Have you received the following immunizations?
Rubella (German measles)
Varicella (Chickenpox)
Hepatitis B
Tetanus/Diphtheria
COVID-19
Other
Lifestyle factors
Rows
Yes
No
Occasionally
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
Obstetric and reproductive history
Rows
Yes
No
Previous pregnancies
13
14
Pregnancy complications
15
16
History of miscarriage
17
18
History of preterm birth
19
20
Fertility treatments
21
22
Do you have any allergies (medication, food, environmental)?
Is there anything else you would like your healthcare provider to know before conception?
Submit Checklist
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