Pregnancy Test Kit Instructions Form
Record your pregnancy test kit details, usage steps, and result interpretation using this clear, step-by-step form.
Kit Brand/Manufacturer
*
Kit Lot Number or Batch Code
Date of Test
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Test
Hour Minutes
AM
PM
AM/PM Option
Did you read the included instructions before starting?
*
Yes
No
Step 1: How did you collect your sample?
*
Midstream (directly onto the test)
Collected in a cup
Other
Step 2: How long did you wait before reading the result?
*
Please Select
Less than 1 minute
1-3 minutes
3-5 minutes
More than 5 minutes
What result did you observe on the test?
*
Positive (two lines or plus sign)
Negative (one line or minus sign)
Invalid (no lines or unclear)
If the result was invalid, what action did you take?
Please Select
Retested with a new kit
Contacted support or pharmacy
Did nothing
Not applicable
Additional notes or observations
Submit Instructions
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