英語

母性健康管理指導事項連絡カード
Maternal Health Management and Guidance Card

年
YY

事業主 殿月MM日
DD

医療機関等名Name of Medical Institution
医師等氏名Name of Dr., etc.

To Employer,

下記の１の者は、健康診査及び保健指導の結果、下記２～４の措置を講ずることが必要であると認めます。

I have confirmed that the patient described below (1) needs to take measures described in the following (2-4) as a result of a checkup andhealth guidance.
記Note
1．氏名 等 Name, etc.
妊娠週数
Weeks ofpregnancy

氏名Name2．指導事項 Guidance items

症状等（該当する症状等を○で囲んでください。）

週 weeks

分娩予定日
Expected date ofdelivery

年YY月MM日DD

指導事項（該当する指導事項欄に○を付けてください。）

Symptoms, etc. (Circle the appropriate symptoms, etc.)

Guidance items (Circle the appropriate symptoms, etc.)
指 導 事 項Guidance

標準措置 Standard measures

措置が必要となる症状等 Symptoms, etc. required to take measures

つわり、妊娠悪阻、貧血、めまい・立ちくらみ、

入院加療 Hospitalization for treatment

腹部緊満感、子宮収縮、腹痛、性器出血、休業
Leave

Abdominal bloating, uterine contraction, abdominal pain,
vaginal bleeding,

勤務時間の短縮 Shortening of working hours

Morning sickness, hyperemesis, anemia, dizziness / vertigo,

自宅療養 Home healthcare

腰痛、痔、静脈瘤、浮腫、手や手首の痛み、身体的負担の大きい作業（注）Back pain, hemorrhoids, varicose vein, edema, pain in thehand or wrist,

Work with heavy physical burden (Note)

頻尿、排尿時痛、残尿感、全身倦怠感、動悸、作
業の制限Frequent urination, pain at the time of urination, feeling ofresidual urine, general malaise, palpitation,
頭痛、血圧の上昇、蛋白尿、妊娠糖尿病、

Restriction of work

Headache, blood pressure rise, proteinuria, diabetes inpregnancy,
赤ちゃん（胎児）が週数に比べ小さい、The baby (fetus) is small for weeks,
多胎妊娠（胎）、産後体調が悪い、

Multiple pregnancy (childbirth,conception), Feeling sick after

妊娠中・産後の不安・不眠・落ち着かないなど、Anxiety / sleeplessness / uneasiness, etc. during pregnancy /after childbirth,
合併症等 Complication, etc. ()長時間の立作業 Standing work for long hours
同一姿勢を強制される作業Work that requires workers to take the same posture

腰に負担のかかる作業

Work with heavy burden on the lower back
寒い場所での作業 Work at a cold place
長時間作業場を離れることのできない作業

Work in which workers can’t leave theworkplace for long hours
ストレス・緊張を多く感じる作業 Stressful work

（注） 「身体的負担の大きい作業」のうち、特定の作業について制限の必要がある場合には、指導事項欄に〇を付けた上で、具体的な作業を○で囲んでください。
(Note） If specific work is restricted out of work with heavy physical burden,
please circle the guidance item field and put 〇 in the specific work.

標準措置に関する具体的内容、標準措置以外の必要な措置等の特記事項
Specific contents on standard measures, special notes of necessary measures other than standard measures, etc.

3．上記２の措置が必要な期間（当面の予定期間に〇を付けてください。）
Period when the measures described in 2 are required to betaken (Circle the scheduled period.)

4．その他の指導事項（措置が必要である場合は○を付けてください。）

Other guidance items(If necessary, please circle the required measures.)1週間 1week (月MM日DD ～月MM日DD)

2週間 2weeks (月MM日DD ～月MM日DD)

4週間 4weeks (月MM日DD ～月MM日DD)

その他 Other (月MM日DD ～月MM日DD)

妊娠中の通勤緩和の措置（在宅勤務を含む。）
Measures for easing commuting during
pregnancy (Including working at home.)
妊娠中の休憩に関する措置

Measures related to taking a rest during
pregnancy

指導事項を守るための措置申請書
Application for taking measures to follow the doctor’s guidance items
上記のとおり、医師等の指導事項に基づく措置を申請します。

年YY

月日

MMDD

I hereby apply for taking measures to follow the doctor’s guidance items mentioned above.

所属 Department
事業主 殿 To Employer,

氏名 Name

この様式の「母性健康管理指導事項連絡カード」の欄には医師等が、また、「指導事項を守るための措置申請書」の欄には女性労働者が記入してください。
The fields for “Maternal Health Management Guidance Items Contact” should be filled in by a doctor, etc. and the fields for “Application for taking measures to follow the doctor’s guidance items” should be filled in by a female worker in this form.

1

（参考）症状等に対して考えられる措置の例 (Reference） Examples of measures considered to be taken for symptoms, etc.
症状名等Name of symptom, etc.

つわり、妊娠悪阻
Morning sickness, hyperemesis
貧血、めまい・立ちくらみ
Anemia, dizziness/ vertigo
腹部緊満感、子宮収縮
Abdominal bloating, uterinecontraction

措置の例 Examples of measures
休業（入院加療)、勤務時間の短縮、身体的負担の大きい作業（長時間作業場を離れることのできない作業)の制限、においがきつい・換気が悪い・高温多湿などのつわり症状を増悪させる環境における作業の制限、通勤緩和、休憩の配慮 など
Leave (hospitalization for treatment), shortening of working hours, restriction of work with heavy physical burden (work in which workers can’t leave the workplace
for long hours), restriction of work in the environment where the odor is heavy/the ventilation is poor/the temperature and humidity are high, which may worsen
the symptoms of morning sickness, easing of commuting, consideration for taking a break, etc.
勤務時間の短縮、身体的負担の大きい作業（高所や不安定な足場での作業）の制限、ストレス・緊張を多く感じる作業の制限、通勤緩和、休憩の配慮 など

Shortening of working hours, restriction of work with heavy physical burden (working at a height or unstable footing), Restriction of stressful
work, easing of commuting, consideration for taking a break, etc.
休業（入院加療・自宅療養）、勤務時間の短縮、身体的負担の大きい作業（長時間の立作業、同一姿勢を強制される作業、長時間作業場所を離れることのできない作業）の制限、通勤緩和、休憩の配慮 など

Leave (hospitalization for treatment, home healthcare), shortening of working hours, restriction of work with heavy physical burden(standing work for long hours, work that requires workers to take the same posture, work in which workers can’t leave the workplace forlong hours), easing of commuting, consideration for taking a break, etc.

腹痛
Abdominal pain

休業（入院加療）、疾患名に応じた主治医等からの具体的な措置 など
Leave (hospitalization for treatment), specific measures from the doctor in charge according to the disease, etc.

性器出血
Vaginal bleeding

休業（入院加療）、疾患名に応じた主治医等からの具体的な措置 など
Leave (hospitalization for treatment), specific measures from the doctor in charge according to the disease, etc.

腰痛
Back pain

休業（自宅療養）、身体的に負担の大きい作業（長時間の立作業、同一姿勢を強制される作業、腰に負担のかかる作業） の制限 など

痔Hemorrhoids

身体的負担の大きい作業（長時間の立作業、同一姿勢を強制される作業)の制限、休憩の配慮 など

静脈瘤
Varicose vein

勤務時間の短縮、身体的負担の大きい作業（長時間の立作業、同一姿勢を強制される作業)の制限、休憩の配慮 など

浮腫
Edema

勤務時間の短縮、身体的負担の大きい作業（長時間の立作業、同一姿勢を強制される作業）の制限、休憩の配慮 など

手や手首の痛み
Pain in the hand or wrist,

身体的負担の大きい作業（同一姿勢を強制される作業）の制限、休憩の配慮 など
Restriction of work with heavy physical burden (work that requires workers to take the same posture), consideration for taking a break, etc.

頻尿、排尿時痛、残尿感
Frequent urination, pain at thetime of urination, feeling ofresidual urine

休業（入院加療・自宅療養）、身体的負担の大きい作業（寒い場所での作業、長時間作業場を離れることのできない作業）の制限、休憩の配慮 など
Leave (hospitalization for treatment, home healthcare), restriction of work with heavy physical burden (work at a cold place, work in which
workers can’t leave the workplace for long hours), consideration for taking a break, etc.

全身倦怠感
General malaise

Leave (home healthcare), restriction of work with heavy physical burden (standing work for long hours, work that requires workers to takethe same posture, work with heavy burden on the lower back）, etc.
Restriction of work with heavy physical burden (standing work for long hours, work that requires workers to take the same posture),consideration for taking a break, etc.
Shortening of working hours, restriction of work with heavy physical burden (standing work for long hours, work that requires workers totake the same posture), consideration for taking a break, etc.
Shortening of working hours, restriction of work with heavy physical burden (standing work for long hours, work that requires workers totake the same posture), consideration for taking a break, etc .

休業（入院加療・自宅療養）、勤務時間の短縮、身体的負担の大きい作業の制限、休憩の配慮、疾患名に応じた主治医等からの具体的な措置 など

Leave (hospitalization for treatment, home healthcare), shortening of working hours, restriction of work with heavy physical burden,
consideration for taking a break, specific measures from the doctor in charge according to the disease, etc.

動悸Palpitation

休業（入院加療・自宅療養）、身体的負担の大きい作業の制限、疾患名に応じた主治医等からの具体的な措置 など

頭痛Headache

休業（入院加療・自宅療養）、身体的負担の大きい作業の制限、疾患名に応じた主治医等からの具体的な措置 など

Leave (hospitalization for treatment, home healthcare), restriction of work with heavy physical burden, specific measures from the doctor incharge according to the disease, etc.
Leave (hospitalization for treatment, home healthcare), restriction of work with heavy physical burden, specific measures from the doctor incharge according to the disease, etc.

血圧の上昇
Blood pressure rise

休業（入院加療・自宅療養）、勤務時間の短縮、身体的負担の大きい作業の制限、ストレス・緊張を多く感じる作業の制限、疾患名に応じた主治医等からの具体的な措置 など
Leave (hospitalization for treatment, home healthcare), shortening of working hours, restriction of work with heavy physical burden, restriction of stressful work,
specific measures from the doctor in charge according to the disease, etc.

蛋白尿Proteinuria

休業（入院加療・自宅療養）、勤務時間の短縮、身体的負担の大きい作業の制限、ストレス・緊張を多く感じる作業の制限 など
Leave (hospitalization for treatment, home healthcare), shortening of working hours, restriction of work with heavy physical burden,
restriction of stressful work, etc.

妊娠糖尿病
Diabetes in pregnancy

休業（入院加療・自宅療養）、疾患名に応じた主治医等からの具体的な措置（インスリン治療中等への配慮） など
Leave (hospitalization for treatment, home healthcare), specific measures from the doctor in charge according to the disease (Consideration
for insulin treatment), etc.

The baby (fetus) is small for weeks

休業（入院加療・自宅療養）、勤務時間の短縮、身体的負担の大きい作業の制限、ストレス・緊張を多く感じる作業の制限、通勤緩和、休憩の配慮 など
Leave (hospitalization for treatment, home healthcare), shortening of working hours, restriction of work with heavy physical burden,
restriction of stressful work, easing of commuting, consideration for taking a break, etc.

多胎妊娠 Multiple pregnancy(胎 conception),休業（入院加療・自宅療養）、勤務時間の短縮、身体的負担の大きい作業の制限、ストレス・緊張を多く感じる作業の制限、通勤緩和、休憩の配慮 など
Leave (hospitalization for treatment, home healthcare), shortening of working hours, restriction of work with heavy physical burden, restriction of stressful work,
easing of commuting, consideration for taking a break, etc.

産後体調が悪いFeeling sick after childbirth

休業（自宅療養）、勤務時間の短縮、身体的負担の大きい作業の制限、ストレス・緊張を多く感じる作業の制限、通勤緩和、休憩の配慮 など
Leave (home healthcare), shortening of working hours, restriction of work with heavy physical burden, restriction of stressful work, easing of commuting,consideration for taking a break, etc.

赤ちゃん（胎児）が週数に比べ小さい

妊娠中・産後の不安・不眠・落ち着かないなど

Anxiety / sleeplessness /uneasiness, etc. during pregnancy / afterchildbirth

合併症等（自由記載）
Complication, etc. (free writing)

休業（入院加療・自宅療養）、勤務時間の短縮、ストレス・緊張を多く感じる作業の制限、通勤緩和、休憩の配慮 など
Leave (hospitalization for treatment, home healthcare), shortening of working hours, restriction of stressful work, easing of commuting,consideration for taking a break, etc.
疾患名に応じた主治医等からの具体的な措置、もしくは上記の症状名等から参照できる措置 など
Specific measures from the doctor in charge according to the disease, or measures that can be referred from the name of the symptoms mentioned above, etc.

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令和５年３月作成 母性健康管理カード（英語）