Obstetric Questionnaire
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Step 1 / 9 Basic Info
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Obstetric Questionnaire

To support the health of both mother and baby,
please share some additional information.

About Prenatal Care at Our Clinic

We provide prenatal care up to 32 weeks of gestation.
Delivery is not performed at our clinic; please arrange a delivery facility separately.
For high-risk pregnancies, we refer patients to a tertiary care hospital early.

About This Questionnaire

  • This will take approximately 10-15 minutes
  • Please have your medication card and maternal handbook ready if available
  • You may select "Unknown" when uncertain
  • Based on Japan Society of Obstetrics & Gynecology Guidelines 2026
  • Data is processed only in your browser until you submit
01

Basic Information

Information carried over from the previous page can be used as-is

Age: － ※Pregnancy at age 35+ is managed as advanced maternal age
cm kg
BMI: －
02

About This Pregnancy

Estimated gestational age: － / EDD: －
★ The cycle is the number of days from the start of one period to the start of the next period
Period Days until the next period Period Start of previous period Start of next period This is the "menstrual cycle" (e.g., 28-day cycle)
If your cycle varies, please indicate the shortest and longest cycle length.
If your cycle is about the same each month, enter the same number in both fields.
days
days
03

Pregnancy & Delivery History

(G)
(P)
times
times
Medically important; you may share in person if preferred
04

Medical History & Surgeries

05

Infection History & Vaccinations

Live vaccines (rubella, measles, varicella) are contraindicated during pregnancy
Cat feces may transmit toxoplasmosis
06

Medications, Supplements & Lifestyle

Drugs during organogenesis (4-10 weeks) may require evaluation for teratogenicity

Lifestyle

No safe level of alcohol is known during pregnancy (FAS risk)
WHO recommends ≤200-300 mg caffeine/day during pregnancy
07

Allergies, Blood Type & Family History

Allergies

Blood Type

Rh(−) patients may need anti-D immunoglobulin

Family History

08

Delivery Facility & Social Support

Our clinic provides prenatal care up to 32 weeks of gestation. Delivery requires arrangement at another facility.
For high-risk pregnancies, we refer to a tertiary care hospital early.

All information is kept strictly confidential. We may coordinate with a midwife or social worker as needed.
09

Consent & Privacy

Privacy Policy

Your information is handled in accordance with Japanese law.

  • Used for clinical care, billing, and administration
  • May be shared with other facilities when clinically necessary
  • Linked to perinatal care networks as needed
  • No disclosure to third parties without your consent
  • Anonymized data may be used for quality improvement

About Prenatal Care

  • We provide prenatal care up to 32 weeks of gestation. Delivery is at another facility.
  • High-risk pregnancies are referred to a tertiary care hospital early.
  • Please obtain a Maternal Handbook (母子健康手帳) from your local government office
  • Bring your prenatal check-up vouchers
  • Please call us anytime if you have concerns
✓

Thank you for completing the obstetric questionnaire

Please use the buttons below

📌 For your visit

  • Print the PDF or show it on your smartphone
  • Please bring your insurance card, patient card, medication card, and maternal handbook
  • New patients: please arrive 15 minutes before your appointment