Hello Everyone! This is a translation of the 妊娠届出書を出された方へ pregnancy forms you must fill out when you go to the Municipal office to register your pregnancy. Please refer to this if your municipal office does not have an English translation and you do not have anyone to help you.

In order to protect the health of the mother and the baby to be born, we ask for you to provide information about your situation during pregnancy to receive consultation and support during your pregnancy. Please note that the information you enter will be treated as personal information to protect your privacy.

1. Is this your first pregnancy?    
 Yes  |   No (1st, 2nd, etc.) time

2. Have you or are you undergoing IVF treatments?
Have (__ years)  | Have not

3. How did you feel when you found out you were pregnant? (More than one answer is okay)
 Happy |  surprised/confused |  Anxious |  I didn't feel anything in particular

4. Is there anyone you can turn to for advice and support about pregnancy, child birth, and childcare?
Yes (Please circle all that apply)
a. husband b. My parents c. husband's parents d. sibling e. friend f. other (_____)
No

5. Do you have a plan as to where you want to give birth?
Yes ( ___prefecture ___city) a. wife's parents' home b. husband's parents' home
No

6. Do you plan to take mother/child classes?
Yes
Scheduled place: a. health and welfare center b. hospital c. other
No

7. Do you smoke tobacco?
No | I stopped when I found out I was pregnant |
Yes (I smoke ___ cigarettes a day. I started smoking at the age of ___)

8. Does anyone in your household/family smoke?
No | They stopped because of the pregnancy
Yes (Relationship (___) ___ cigarettes a day | Relationship (_____) _____cigarettes a day

9. Do you drink alcohol?
No | I stopped when I found out I was pregnant
Yes  Everyday | sometimes  | Drink about _____ (oz./ml./l) a day

10. What illnesses have you had up until now?
None
Have a. hypertension b. inflammation of the kidneys c. diabetes d. heart disease e. Thyroid illness f. mental illness f. Other (__________)

Have you ever had surgery?
No | Yes (Name:_____)

11.  Are you currently prescribed any medications?
No
Yes (Disease name/symptoms_________)
Are you undergoing treatments? Yes | No
Name of Medical institution (____________________)
Name of medication (__________________)

12. Is there anything you are worried about or want to discuss? (Multiple answers are okay)
1. My body during pregnancy
2. housework and work
3. childbirth and childcare expenses
4. financial things
5. Relationship with partner (physical/mental abuse)
6. I don't have anyone to talk/support me
7. Daycare and nursery


_______________________________
Please provide information about the pregnant woman and her family

13. About husband (partner)
Name | date of birth | age | occupation

14. About pregnant woman and husband (partner): 
Married | Unmarried | Plan to get married (yes | no)
Plan to move (yes | no)( relocation address: ________)

15. About household
Including pregnant women (___people)
1. husband (partner) | 2. children (____) Age(s) (_____)
2. Wife's Mother/Father 3. Husbands (Mother/Father) | Other (_______)

16. About Health insurance
Enrolled | Not enrolled

17. Daytime Contact
How to contact during the daytime
Wife/husband/Other（_____）Phone number (_____)
Times it is easy to contact (between this　 hr to this　hr)

Wife/husband/Other（_____）Phone number (_____)
Times it is easy to contact(between this  hr  to this 　hr)

I agree to the following

1. Receive a letter during the second half of my pregnancy
2. When I move from the city, I agree to receive a letter from the new ward during the second half of pregnancy
3. When I move from the city, provide information and notify the new ward of my pregnancy

Signature: ______________