Pregnancy Notification Form/Year/Month/Day

To: Mayor of Beppu City
※Fill in only if you are a substitute.

Notified by (Name of thepregnant woman) Relationship with the pregnant woman (In accordance with the provisions of Article 15 of the Maternal and Child Health Act,the following pregnancy notification shall be made.
(Furigana)Birth of/Year/MonthDate/Date

Age:Occupation

My Number＊Fill out at the service
counter.

HomeBeppu City
AddressTELMobile
Theth week

Weeks of pregnancy
The 1st / 2nd / 3rd/
Expected delivery datechild/Year/Month/Date

Age on the day of the delivery:

Name of the doctor or midwife who diagnosed the pregnancy
Physical examination (chest x-ray)
regarding tuberculosis in thispregnancy

Taken / Not taken /don't know

Taken / Not taken /don't know

Physical examination (blood test)
for STDs in this pregnancy

対応者

（）

受付窓口記載欄
交付日
交付番号
個人番号確認
身元確認
代理人の確認代理人の身元確認

年月日

母子手帳

入力：

外国語版

入力：

・個人番号カード ・通知カード ・住民票
・健康管理システム ・その他（）
・個人番号カード ・運転免許証 ・住民票
・官公庁から発行された書類 ・その他（・委任状・電話・その他（・住民基本台帳））

・個人番号カード ・運転免許証 ・住民票
・官公庁から発行された書類 ・その他（・住民基本台帳）
受付印)

※ Please be sure to read this information.
The Beppu City provides consultation and information for safe and secure pregnancy, delivery and child rearing. Please
fill out the following questionnaire to the possible extent.
Also, if you agree to provide the information by the city on the Pregnancy Notification Form and the items (1) to (15) inthis questionnaire to the medical institution where you were diagnosed as pregnant, or to the medical institution or
midwifery facility where you plan to give birth, please sign in the box below.
Name/Year/Month

About your pregnancy

Pregnancy

th week

For those pregnant for more than 16 weeks, please answer the reason why the notification wasdelayed.
(1) I didn't have time (2) I wasn't feeling well. (3) I wasn't sure if I wanted to have the baby ornot.
(4) I didn't realize I was pregnant. (5) I didn't know how to report.
(6) Other ()Name of the medical institution or midwifery
facility where the baby will be delivered

About your family

Husband(Partner)
Familymembers(Furigana)

Date ofbirth/Year/Month(Age:/Day)Occu
pationNumber of people living together ()Please circle the family members who live with you: husband/partner/children (number:father/) / myAbout the pregnant woman herself① If you are currently employed, you work:・full-time / part-time / self-employed・Do you plan to quit?

Yes / No・Can you take maternity leave? Yes (fromweeks before childbirth)/ N② How did you feel when you found out you were pregnant this time?

I was very happy / I wasn't expecting it, but I was happy / I wasn't expecting it, so I was surprised and confused / I
was troubled / I didn't think anything of it.
③ How did your husband (or partner) react when you found out you were pregnant this time?

He was pleased / He wasn't pleased / I can't say either / I didn't tell him.
・For those not yet registered as a married couple, ※Do you plan to get married in the future? Yes / No / Undecided④ Do you have any illnesses that you have had or are currently being treated for?

No / Yes ⇒ Name of the disease: high blood pressure, kidney disease, diabetes, heart disease, thyroid disease,other ()
⑤ Have you experienced any of the following in your previous pregnancies and births?
No / Yes ⇒ gestational hypertension / gestational diabetes / impending miscarriage / preterm birth / stillbirth /delivery of a child weighing less than 2500 grams / other ()⑥ Do you have any concerns or stresses about your current or future life?

Please circle all that apply.
About my child / about my body during your pregnancy / about childbirth / about childcare / about my older child /things with my husband (partner) (violence, etc.) / things with my own parents (parents-in-law) / housework / work /the cost of childbirth and childcare / other () / None

⑦ Have you ever consulted a counselor, psychologist, psychiatrist, etc.?

No / Yes (when?

)⑧ What is your current height, weight and non-pregnancy weight?

Height (cm) / current weight (kg) / weight at non-pregnancy (kg)

⑨ Please circle all that apply to your recent mental and physical condition.

Severe morning sickness / irritability / tiredness / not sleeping well / depression
other () / I am in good shape.

⑩ Do you and your family smoke?
(You) I don't smoke / I quit before I became pregnant / I quit after I became pregnant / I plan to quit / I smoke (cigarettes/day)(Family) They don't smoke / They quit before you became pregnant / They plan to quit / They smoke (cigarettes/day)※ At home (no smoking / separation of smoking areas / we haven't done anything.)⑪ Do you drink alcohol?
I don't drink to begin with / I haven't had a drink since I was pregnant / I drink ()times/week type:

quantity:⑫ Do you have someone you can talk to about what you are worried or stressed about during pregnancy and after the birth?

Yes

Husband (partner) / parents / parents-in-law / siblings / friends
Noother ()⑬ Do you have someone to help you with household chores, childcare, etc. during your pregnancy or after the birth?
Yes
Husband (partner) / parents / parents-in-law / siblings / friends
Noother ()⑭ Do you have plans to return home?
Yes (when:how long:) Hometown ()NoUndecided⑮ Do you know about perinatal visits?

YesNo❉If you have any questions about pregnancy, childbirth, or childcare, please fill out the form.

Thank you for your cooperation.
Please feel free to contact the Beppu City Children and Family Division if you need advice on pregnancy, childbirth or childcare.

Your health care provider may also contact you depending on this pregnancy form and questionnaire.
Thank you for your understanding.