Preconception Counseling Questionnaire
What a preconception counseling questionnaire asks, with sample questions on pregnancy plans, medicines, health, and lifestyle.
A preconception counseling questionnaire records pregnancy plans, past pregnancies, medicines, health conditions, diet, and lifestyle before a visit about becoming pregnant. It's also called a preconception questionnaire.
Preconception counseling questionnaire, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a preconception counseling questionnaire in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample preconception counseling questionnaire questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- When are you planning to become pregnant?Pregnancy plans
- What are your biggest concerns about having a baby?Pregnancy plans
- How many previous pregnancies have you had?Pregnancy history
- Did you have difficulty getting pregnant last time?Pregnancy history
- Do you take any prescription drugs?Medications
- Do you use herbal remedies or alternative medicine?Medications
- Have you had the measles, mumps, and rubella vaccine?Medical history
- Do you have epilepsy, diabetes, or high blood pressure?Medical history
- Do you take folic acid?Diet
- Do you follow a special diet?Diet
- Do you smoke or use other tobacco products?Lifestyle
- Do you work near chemicals, radiation, or lead?Lifestyle
These are examples to read, not a form to fill in.
Preconception counseling questionnaire: FAQ
What does a preconception counseling questionnaire ask?
The sample questions on this page are based on El Camino Health's Preconception Personal Assessment Questionnaire and the Los Angeles County Department of Public Health preconception checklist. This page groups them into six areas: pregnancy plans, pregnancy history, medications, medical history, diet, and lifestyle.
Who fills in a preconception counseling questionnaire, and when?
The patient, before the first preconception appointment. El Camino Health asks patients to bring the completed form and review it with their doctor or midwife.
What is the questionnaire for?
El Camino Health says its questionnaire helps patients find questions to ask and areas where they want more information or resources.
Is it the same as a planning pregnancy checklist?
It can be. The Los Angeles County version is a checklist: the patient marks each question with a yes answer and fills in the details.
Does it ask about pets and the home?
Yes. The Los Angeles County checklist asks about pets, contact with soil, cat litter, or sandboxes, and a place for a baby to sleep.
Is there a preconception counseling questionnaire template?
The sample questions on this page show a typical set.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
