Section 1: Personal Information
1. Name:
2. Age:
3. Number of Children:
4. Age of Youngest Child:
5. Occupation:
6. Location:
7. Marital Status:
• Single
• Married
• Divorced
• Widowed
Section 2: Reproductive History
1. Total number of pregnancies (including current, if applicable):
2. Average interval between pregnancies:
3. Number of live births:
4. Number of miscarriages or stillbirths:
5. Any history of preterm births?
• Yes
• No
• If yes, please specify: ___________________
6. Complications during pregnancy or childbirth (e.g., preeclampsia, gestational diabetes, postpartum
hemorrhage):
• Yes
• No
7. LMP
Section 3: Medical History
1. Have you been diagnosed with any chronic health conditions? (e.g., diabetes, hypertension, thyroid
disorders)
• Yes
• No
2. Have you ever been diagnosed with anemia?
• Yes
• No
3. Do you have any current medical conditions that require ongoing treatment or monitoring?
• Yes
• No
Section 4: Nutritional Assessment
1. How would you rate your overall diet?
2. Do you take any vitamin or mineral supplements?
• Yes
• No
3. Do you follow vegetarian or non vegetarian diet?
4. Do you follow any specific dietary restrictions or special diets? (e.g., vegetarian, vegan, gluten-free)
• Yes
• No
Section 5: Breastfeeding Practices
1. Are you currently breastfeeding?
• Yes
• No
2. How long do you typically breastfeed each child?
3. Have you experienced any challenges with breastfeeding? (e.g., low milk supply, pain, infections)
• Yes
• No
4. Do you supplement breastfeeding with formula or other foods?
• Yes
• No
Section 6: Physical and Mental Health
1. How often do you feel fatigued or exhausted?
2. In the past year, have you experienced any of the following symptoms? (Check all that apply)
3. How would you rate your overall physical health?
4. How would you rate your overall mental health?
5. Do you feel you have adequate support (family, friends, healthcare) for your physical and mental
well-being?
• Yes
• No
Section 7: Healthcare Access
1. How often do you visit a healthcare provider for check-ups?
2. Do you have access to prenatal and postnatal care?
• Yes
• No
3. Have you attended any prenatal or postnatal classes or received educational materials?
• Yes
• No
4. Do you have know about family planning?
• Yes
• No
Section 8: Socioeconomic Factors
1. What is your household income level?
• Low
• Middle
• High
2. Do you have access to clean water and sanitation facilities?
• Yes
• No
3. Do you have any financial constraints that affect your ability to access nutritious food or
healthcare?
• Yes
• No
Section 9. Current Pregnancy (if applicable)
1. Are you currently pregnant?
• Yes
• No
2. If yes, how many weeks pregnant are you?
• Less than 12 weeks
• 12-24 weeks
• More than 24 weeks
3. Have you experienced any complications during this pregnancy? (Check all that apply)
• Morning sickness
• Gestational diabetes
• High blood pressure
• Preterm contractions
• Vaginal bleeding
• Severe fatigue
• Other (please specify): ___________________
