Patients Visiting the Oral Surgery Outpatient Clinic ＜Medical Questionnaire＞

Name：

Age：

Occupation：

Patient ID Number：Contact number (No. where the hospital can reach you) Tel：

Nationality：

To have a comfortable and safe oral surgery consultation, it is very important for us to know about your physical condition.
Please answer the questions below.
 What is the reason for your visit today? Please write down your symptoms in detail.
(Example: gums are swollen, jaw joints hurt, an ulcer on the tongue, tooth removal, etc.）
When did these symptoms appear?
 Have you ever developed a serious or significant condition? ( YESNO )Please circle the following or fill-in the ‘others’ section if you have any known diseases.
Asthma ・ Diabetes ・ High blood pressure ・ Heart disease ・ Liver disease ・ Kidney disease ・ Blood
disease ・ Gastroenterological disease ・ Osteoporosis
Others ( Are you currently having consultations at a hospital?
(YESNO)
St. Luke’s International Hospital ・ Another hospital than St. Luke’s Hospital:
Dept.:
 Do you currently take any medicine?
(YESNO)
Please check the following or write down the names of the medicine.
☐ Only medicines prescribed at St. Luke’s☐ I have my “Medication Notebook” with me☐ Name(s) of medicine(s) Are you allergic to any medicine?
(YESNO)
Please write the name of the medicine and your reaction.
 Do you have any allergies other than to medicine?
(YESNO)(Example： Latex, metal, food, etc.)
 Have you ever been told you have high blood pressure?

(YESNO) B.P

 Is it hard for bleeding to stop once you start to bleed?

(YESNO) Have you ever had a tooth removed?

( YESNO ) Have you ever had dental anesthesia?

( YESNO ) Were there any abnormalities when you had a tooth removed or during anesthesia?

）/(YESNO)

Please describe the abnormality in detail. (Example: Nausea)(Continued on the following page)〒104-8560 東京都中央区明石町 9-1 Tel.03-3541-5151 Fax. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.
English-language sentences shall conform to their Japanese-language counterparts.
Any legal responsibility involved shall be governed and construed based on Japanese-language sentences.

 Please circle the following number that best represents how difficult the past week has been for you.
０１２３４５６７

８

９No problems at all

10

Extremely difficult

To what extent did that difficulty affect your daily life?
０１２

３

４

５

６

７

８

９

10Not at all Do you smoke?

Extremely☐ Yes, currently ☐ Used toNumber of cigarettes☐ Have never smoked/day

 Do you drink alcohol? NO ・ YES ( Every day ・ Every week ・ Sometimes ) For womenCurrently☐ Pregnant

Currently☐ Breastfeedingmonths☐ Unsure☐ Not pregnant☐ Not breastfeeding At St. Luke's International Hospital, patients are treated with blood transfusion when deemed medically necessary.
Do you agree to undergo blood transfusion if necessary?

(YESNO) Are you scheduled to donate blood for autologous or regular transfusion at this or another hospital? (YESNO) Other: Please write down anything you wish to inquire or are concerned about.

230425_Ver.4.00_A4 白黒片面左ホッチキス〒104-8560 東京都中央区明石町 9-1 Tel.03-3541-5151 Fax. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.
English-language sentences shall conform to their Japanese-language counterparts.
Any legal responsibility involved shall be governed and construed based on Japanese-language sentences.