Preconception Health Questionnaire Form
A concise questionnaire for people planning pregnancy. Share your basic background, timeline, and readiness details so the form can capture the information needed for preconception guidance.
Respondent Information
First Name
*
Last Name
*
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Preconception Timeline and Pregnancy Goal
Are you trying to conceive now or planning to conceive soon?
*
Trying now
Planning within 3 months
Planning within 6 months
Planning in more than 6 months
Not planning at this time
If planning, when do you intend to start trying?
Please Select
Now
Within 3 months
Within 6 months
More than 6 months
Medical and Medication Overview
Current medications or supplements
Known medical conditions
Diabetes
High blood pressure
Thyroid condition
Asthma
Autoimmune condition
History of blood clots
Epilepsy or seizures
PCOS
Endometriosis
Depression or anxiety
Other
Allergies
Cycle and Fertility History
Menstrual cycle regularity
*
Regular
Irregular
Not sure
Not applicable
Date of last menstrual period
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Prior pregnancy history or fertility concern to note
No
Yes
Prefer to describe
Lifestyle and Habits
Smoking or vaping status
*
Never
Former
Currently using
Prefer not to say
Alcohol use
Never
Monthly or less
2-4 times a month
2-3 times a week
4 or more times a week
Prefer not to say
Exercise or nutrition concerns
Support Needs and Notes
Main questions or concerns about preparing for pregnancy
Preferred contact method for follow-up
*
Email
Phone
No follow-up
Additional notes for the provider
Submit Questionnaire
Should be Empty: