Obstetric Preconception Planning Questionnaire
Personal Information
Full Name
Date of Birth
Contact Number
Medical History
Previous Pregnancies (number and outcome)
Chronic Illnesses (e.g., hypertension, diabetes)
Allergies
Current Medications
Gynecological History
Menstrual Cycle Details (length, regularity, etc.)
History of Sexually Transmitted Infections
Lifestyle & Family History
Smoking
No
Yes
Former Smoker
Alcohol Use
No
Yes
Former User
Family History of Genetic Disorders
Other Notes
Additional Comments or Concerns