5 歳児セルフチェック表

Parent Checklist for 5-Year Olds
<以下のことについてチェックしてみましょう＞< Please provide the following information.>
１お子さんの健康状態や、子育てについてお聞きします。

Answer the following questions about your child’s health conditions and your concerns about childrearing.
① Does your child’s kindergarten or daycare center provide health

Yes

No

② Do you have any concerns about your child’s diet?

NoYes③ Do you have any concerns about your child’s physical

No

Yes

checkups?

development (height/weight/form)?

APlease consult the growth chartin your Maternal and Child Health Handbook to see whether your child falls in thehealthy range. (The chart is right before the immunization record.)④ Do you have any concerns about your child’s posture or way ofNoYes

NoYes

walking/running?
⑤ Are you afraid that your child might have poor eyesight? (Pleasecheck your child’s eyesight using the sheet enclosed.)⑥ Are you afraid that your child might have a hearing problem?

BNoYes(Please complete the hearing test enclosed.)

２

お子さんの発達について、はい、いいえのどちらかに○をつけてください。
（運動・社会性・ことばの発達についての質問です。）

Please mark either Yes or No about your child’s physical/social skills and language development.

My childYes

No① can skip.
② can play on a swing without being pushed.
③ can hop on one foot.
④ can imitate you drawing a square.
⑤ can defecate in the toilet by him/herself.
⑥ can button/unbutton clothing.
⑦ can play in groups.
⑧ can tell who won in Rock Paper Scissors.
⑨ can read his/her own name.
⑩ can articulate/pronounce words clearly.
⑪ can tell left from right.
⑫ can wait for his/her turn.
⑬ can enjoy hide-and-seek or tag following the rules.

C３

お子さんの様子に合う欄に○をつけてください。（保護者の方や保育者の方からみて、気になる様子についての質問です。）

Please check the rows below to tell us how you feel about each statement.
(These are questions about concerns from the viewpoint of parents/caregivers)

CI am
My child

notslightly

very

worriedworriedworried① is easily distracted by stimulation from outside.
② does not understand me sometimes.
③ cannot sit still.
④ is restless. (hyperactive)⑤ tends to get in trouble with friends.
⑥ tends to be short-tempered.
⑦ doesn’t pay attention to me when I tell him/her
what to do or what not to do.
⑧ does only what he/she likes.
⑨ cannot play well with friends.
⑩ often plays alone.
⑪ tends to do things his/her own way⑫ is clumsy when using utensils like chopsticks andscissors.
⑬ does not articulate/pronounce clearly.
⑭ cannot express his/her feelings well.
⑮ cannot understand other people’s feelings well .
⑯ does not listen or communicate well with others.
⑰ gets easily confused by a change in daily routine.
４ お子さんの様子やからだのこと、子育てについて相談したい事はありますか。いいえ はいDo you have any concerns about your child? (about his/her health, development, behavior or child-rearing)
Topics you would like to discuss:[]
ANoYes

① If you marked (checked) the shaded area of section A, it is recommended that you have your child go
through the “Health Check for 5-year Olds (5 Sai-ji Kenshin).”② If you marked the shaded area of section B but did not mark the shaded area of section A, it isrecommended that you have your child consult an otolaryngologist/ophthalmologist.
③ If you marked the shaded area of section C but did not mark the shaded area of section A, it isrecommended that you make an appointment for the “Developmental Consultation for 5-year Olds (5Sai-ji Hattatsu Sodan).”*If you are already consulting a specialist regarding your concerns, no additional consultation isrequired.

受診を希望されない場合は以下の記入は不要です

Only provide the following information if you wish to receive 5-year old healthcheckup.
★5歳児健診を受診される場合は、下記も記入してください。 お住まいの区の保健センターに電話予約が必要です。
※下記の枠内に記載の上、予約日当日に母子健康手帳と一緒に保健センターへお持ちください。
予約日
年月日（曜日）：～：★Fill in the following and bring this form to the health center with the Maternal and Child Health
Handbook on the day of the health checkup.
★Please call the health center of your ward in advance to make an appointment.
yearYour appointment date:(Time:(ご家 族

※同居の方

家族の氏名
Name of family
members/:

続柄
relationship

Familyday,

齢 等

year /month/ day//() years oldyear /month/ day//

母Motherwith the(child)) years oldyear /month/ day//() years oldyear /month/ day//() years oldyear /month/ day//(da y of t he we e k:date of birth / age(Peoplewho reside/～年

父Fatherを含みますmonth) years old))

健康状態・治療中の病気
Condition of health

職業、学校、幼稚園等
Occupation, school,kindergarten, daycare, etc.

良・治療中
Healthy/
Receiving treatment
for ()
良・治療中
Healthy/
Receiving treatment
for ()
良・治療中
Healthy/
Receiving treatment
for ()
良・治療中
Healthy/
Receiving treatment
for ()
良・治療中
Healthy/
Receiving treatment
for ()

このアンケートに記入された方はどなたですか

母親・父親・その他（Mother / Father / Other (本日の健診、発達相談に同伴された方はどなたですか

母親・父親・祖父母・その他（Mother / Father / Grandparent / Other (Who is completing this questionnaire?
Who is attending the health check with the child?

Name ofFamily namegiven nameDate of birth住Male/Female)

Yearthe child(））)/ month/ day//)

所

Address(Tel.)(E-mail)Nationality
お子さんは保育園・幼稚園に通っていますか

Is your child attending daycare/kindergarten?

Yes / No
(Name of the facility:)

・これまで受けた予防接種① BCG ②四種混合 ③ポリオ ④ＭＲ（麻しん風しん混合ワクチン）○7 日本脳炎 ⑨B型肝炎 ⑩その他【ロタ・おたふく・左記以外】⑤ヒブ ⑥小児用肺炎球菌 ⑦水痘

Immunization record (Circle the vaccinations your child has received.)

○
1 BCG

② DPT-IPV (or DPT and Polio ) ○3 MＲ(Measles and Rubella)○
4 Haemophilus influenzae type B vaccine (Hib)○
6 Chickenpox ○7 Japanese encephalitis○
5 Pediatric pneumococcal vaccine○
8 Hepatitis B○
9 Rotavirus, Mumps, other ()・今までかかった病気（治ったもの）なし・あり （病名：医療機関名：）

Has your child had any medical problems? （Include illnesses that have been cured.）
No / Yes
If yes,（Name of illness :）（Name of the hospital/clinic :・通院中の病気 なし ・ あり （病名：）

医療機関名：）

Is your child currently receiving medical treatment?

No/ YesIf yes,（Name of illness :）（Name of the hospital/clinic :・これまでに受けた健診）

4か月児健診・10か月児健診・1歳6か月児健診・3歳児健診

Health checks undergone: 4 months / 10 months / 18 months / 3 years
・どんな遊びが好きですか

What kind of play does he/she like? （・同じ年齢くらいの遊び友達はいますかはい）

いいえDoes he/she have friends around the same age?
・起床・就寝時間を記入してください

起床 （：）

就寝 （：Yes / No）

What time does he/she wake up and go to bed?
Wakes up at (・家庭での食事やおやつの時間はだいたい決まっていますか:) Goes to bed at (決まっている 決まっていない

Does he/she eat meals and snacks on a regular schedule?
・毎日歯を磨く習慣がありますか

はいYes /No

いいえ

Does he/she have a habit of brushing his/her teeth every day?
・歯科医院に行ったことがありますか:

いいえ

Yes /Noはい （①治療 ②フッ化物塗布 ③定期健診）

Has he/she ever visited the dentist?

No / Yes

If yes, the visit was for (○1 treatment ② fluoride application ③ regular checkup ）・テレビやＤＶＤをどのくらい見ますか

1日 （）時間

How long does he/she watch TV or other devices?

() hour(s) a day)

Health Centers in Sapporo City
Please contact the health center of your ward for appointments and inquiries.

名称

郵便番号

所在地

電話番号

Name

Postal CodeAddress

Telephone Number

中央保健センター

060-0063

Chuo Health Center

札幌市中央区大通西2丁目9011-205-3352

kita 1-jo Nishi 2-chome, Chuoku

北保健センター001-0025

Kita Health Center

札幌市北区北25条西6丁目

011-757-1181

Kita 25-jo Nishi 6-chome, Kitaku

東保健センター065-0010

Higashi Health Center

札幌市東区北10条東7丁目

011-711-3211

Kita 10-jo Higashi 7-chome,Higashi-ku

白石保健センター

003-8612

Shiroishi Health Center札幌市白石区南郷通１丁目南8011-862-1881

Hongo-dori 3-chome Kita,
Shiroishi-ku

厚別保健センター

004-8612

札幌市厚別区厚別中央１条5丁目

Atsubetsu HealthAtsubetsu Chuo 1-jo 5-chome,

CenterAtsubetsu-ku

豊平保健センター

062-8612

Toyohira Health Center

札幌市豊平区平岸6条10丁目

011-895-1881

011-822-2472

Hiragishi 6-jo 10-chome,
Toyohira-ku

清田保健センター

004-8613

Kiyota Health Center

札幌市清田区平岡1条1丁目

011-889-2049

Hiraoka 1-jo 1-chome, Kiyotaku

南保健センター005-0014

Minami Health Center

札幌市南区真駒内幸町 1 丁目

011-581-5211

Saiwai-machi 1-chome,
Makomanai, Minami-ku

西保健センター063-0812

Nishi Health Center
手稲保健センター
Teine Health Center

札幌市西区琴似2条7丁目

011-621-4241

Kotoni 2-jo 7-chome, Nishi-ku
006-8612

札幌市手稲区前田1条11丁目
Maeda 1-jo 11-chome, Teineku

011-681-1211