Kadubi Holistics - Pregnancy Wellness Assessment

Personal Details

Symptoms Assessment

Back Pain

No Back Pain

Mild Back Pain

Moderate Back Pain

Severe Persistent Pain

Pelvic Pain

No Pelvic Pain

Mild Pelvic Pain

Moderate Pelvic Pain

Severe Pelvic Pain

Calf / Feet Cramps

No Cramps

Occasional Cramps

Frequent Cramps

Severe Sleep Disturbing Cramps

Swelling in Feet

No Swelling

Mild Evening Swelling

Frequent Swelling

Severe Swelling

Acidity / Gastritis

Rarely / Never

Occasional Acidity

Frequent Acidity

Severe Daily Acidity

Breathlessness

Rarely/normal pregnancy

Mild occasional breathlessness

Frequent breathlessness

Severe discomfort affecting

Gestational Diabetes

Normal blood sugar

Borderline elevated sugar

Diagnosed gestational diabetes

Poorly controlled gestational diabetes hypertension

Nausea / Vomiting

Minimal/no nausea

Mild occasional nausea

Frequent nausea/vomiting under control

Severe symptoms affecting food intake diabetes hypertension

Placenta Previa / Low-Lying Placenta

No

Mild low-lying placenta under observation

Confirmed placenta previa with precautions

Significant restrictions/high-risk monitoring

Constipation

Rarely/never

Mild occasional constipation observation

Frequent constipation

Severe persistent constipation

Fatigue

Energetic most days

Mild tiredness

Frequent fatigue

Severe exhaustion affecting

Lifestyle Wellness

Daily Water Intake

Less than 1 litre

1–2 litres

2–3 litres

More than 3 litres

Physical Activity

Completely Sedentary

Occasionally Active

Daily Walking

Regular Pregnancy Yoga

Sleep Quality

Very Disturbed Sleep

Inconsistent Sleep

Mostly Restful Sleep

Excellent Recovery Sleep

Meal Routine

Frequently Skip Meals

Irregular Eating Habits

Mostly Regular Meals

Balanced Nutritious Meals

Protein-rich foods

Rarely

Sometimes

Daily

Intentionally prioritizing protein intake

Supplements

Frequently forget

Miss occasionally

Mostly regular

Very consistent protein intake

Screen time

More than 8 hours

5-8 hours

2-5 hours

Less than 2 hours

Emotional Wellness

Stress / Mood Swings

Emotionally stable

Mild mood fluctuations

Frequent stress/mood swings

Severe emotional distress/anxiety activity