Pregnancy Notification Form

Submit to the Mayer of Yachiyo city

英語版

Pregnant herself, husband, mother, father, and the other (Relationship with pregnant...............................................................)Name of the reporter:

Example:Year 20

Example numbers:

DateMonth

レ Check the box which is relevant to you
Resident
address

YACHIYOSHI

八千代市
Years ofresidence inYachiyo city

Pronunciation

Name ofpregnant
TEL ofpregnant―

TEL ofspouse―

Pregnant’s
date ofbirth
Expected dateof delivery

昭和□ □平成（YearYear20

Occupation ofpregnant
Type of health National, Social, Fraternal insurance
insurance
Other ()

―BirthExperience―Month□ Yes□ No

Weeks ofpregnancy

Date(Age:）Month....................Year................MonthHow many children
are expected to beborn?

)

Are you goingparents forchildbirth?

DateWeeks□ Just one □ Twins □ Triplets
Yes□ Prefecture(）□ No □

Undecided

Name of※Write name of medical facility center that diagnosed your pregnancy and gave health guidance support.
medical facility
Name of the hospital:
Address:
centerDateofbirth
Date of birth
FamilyName
Age Relation occupation
NameAge Relation occupation
structure(Write down therelationshipseen frompregnant)Please answer following questions and check the box which is relevant to you.
HeartHigh blood pressure□ No □□ diseas □ Kidneydisease □Mental)) □ Other(□ disorder (How did you feel when you found out□ Happy □ Not too bad□ Not very happy □ Not happy
you are pregnant?
Do you feel anxiety or confusion?
□ No □ Hardly□ Yes□ Feel anxiety and confused
Do you feel financial difficulty?
□ No □ A little □ Yes→
between family, Family’s health, Compatible with
Are you worried about your family or life? □ No
□ Yes→ Relationshipwork, Other()Do you have anyone who are counselor orParents of□ No □ □ Parents □ husband □ Siblings □ Friends
supporter for your parenting?
Do you smork?
□ No □ Quit
□ Yes
Is there anyone who smoke in your family? □ No)□ □□ Siblings □ Other(
Do you drink alcohol? (Sake, beer, wine, etc.) □ Everyday □ Sometimes □ Never after being pregnancy □ Never

Have you ever attended a medical
institution for disease regularly?

Tuberculosis

Medical checkup, Maternity coverage, Cost of after childbirth,
Other()

Husband

HusbandParents

If you have anything you would like to ask us, write these down below

Remarks

交付番号□ 交付(双子用 □ 交付外国語版)語

受付サイン

□ F

交付場所

処理コード

妊娠期から乳幼児期の保健福祉サービス等につい□ て、子ども支援センターすてっぷ２１・地域子育て支援センター、母子保健課よりご連絡させていただくことがあります。

This notification form won’t be used other than the purpose of child care support such as mother and child’s health care. Also we will storage and manage this withincommunity health center.

You need social security number and identity in order to notify pregnancy
Collected social security number will be used only for the following purposes, and will be kept securely
Purpose of use of personal information
・Notification of pregnancy, delivery of maternal and child health handbook, health checkup, home-visit instruction, healthguidance, and notification of low weight baby according to the maternal and child health law
・Make of victim’s ledger according to the disaster control measure law

Write down name of the pregnant and the social security number below
Name

Social securitynumber(12 digits)

The space provided below is used for office processing. Please do not fill in.

八千代市民である確認に用いた書類

運転免許証 ・健康保険証 ・外国籍の場合は在留カード ・その他（）

委任状の確認※妊婦以外が届け出た場合のみ□委任状受け取り）

代理人の身元確認→ 運転免許証・健康保険証・その他（以下は個人番号の記入があった場合に確認届出人が「妊婦本人」の場合
１ 個人番号確認 → 個人番号カード または 通知カード または 個人番号が記載された住民票の写し
２ 身 元 確 認 → （1点で可）個人番号カード または 運転免許証 または パスポート（2点で可）健康保険証 と 年金手帳
届出人が「代理人」の場合→【夫・母・父・その他（妊婦との関係）】
１ 妊婦の個人番号確認→ 妊婦の個人番号カード または 妊婦の通知カード または 個人番号が記載された住民票の写し
２ 代理人の身元確認 →（1点で可） 代理人の個人番号カード または 運転免許証 または パスポート（2点で可） 代理人の健康保険証 と 年金手帳
３ 代 理 権 の 確 認 → 委任状 または 妊婦が20歳未満で親権者が代理人の場合は戸籍謄本

Contact: yachiyo city office child department maternal and child health division (yachiyo city health center)

TEL ：047（486）7250