YearGeneral Medical Inquiry Form 医科問診票

20年Month Day
月日

It is very important to know your medical history and state of health. All information given here is strictly confidential.
あなたの既往症と体調を事前に把握しておく事は大切な事です。個人情報の秘匿は守られます。

General Patient Information 患者の情報
フリガナ：

Last name 姓
Male男First name(s) 名Female

Date of Birth 生年月日女

Occupation 職業Year:

Nationality 国籍

Month:

Addressin Japan
日本での住所Day:

Language(s) 言語
Phone number 電話
E-mail/fax メール・ファックス

Chief Complaint(s) 主訴
Fever, hightemperature 熱Itching かゆみ

High blood pressure 高血圧

Weight loss/gain 体重減少・増加CNausea 吐き気

Chest pain 胸痛

Pain in... 痛み

Vomiting 嘔吐

Shortness of breath 息切れ

Stomachache 腹痛

Palpitations 動悸Burns やけど

Diarrhea 下痢

Dizziness めまい

Injury 外傷

Blood in stool 血便

Ringing in ears 耳鳴り

Sprain 捻挫

Blood in urine 血尿Numbness しびれ

Lump しこり

Discomfort urinating
排尿痛

Swelling むくみ

Tumor 腫瘤

Fatigue 疲れやすい

Hemorrhoid 痔Chills 寒気
Headache 頭痛
Sore throat 咽頭痛
Runny nose 鼻水
Cough 咳Rash 発疹
Other (please write) 他

How long have you had this? どのくらい？

hour(s) 時間

day(s) 日間

week(s) 週間

month(s) ヶ月

year(s) 年間

Illness and Surgical History 既往歴、手術歴
Please select any illnesses you have had. 該当する疾患に印をつけて下さい
High blood pressure 高血圧

Kidney disease 腎臓病

Convulsions or Epilepsy けいれん･てんかん

Diabetes 糖尿病

Liver disease 肝臓病

Tuberculosis 結核

Heart disease 心疾患

Thyroid problems 甲状腺異常

Hepatitis B or C B/C型肝炎

Cerebrovascular disease 脳血管疾患

Asthma 喘息

HIV エイズ

Other (please write) 他
Have you had any operations before? 手術暦
No
Yes
What? 何の手術
Have you had a blood transfusion? 輸血暦
NoYes
What was it for? 何の為Do you tend to bleed much? 出血傾向 NoYes

Not sure

わからないFamily History 家族歴
Please select any illnesses your immediate family have had. 親族でのHigh blood pressure 高血圧

Kidney disease 腎臓病

Cancer 癌

Diabetes 糖尿病

Liver disease 肝臓病

Hereditary diseases 遺伝子関連疾患

Other (please write) 他

Go to REVERSE SIDE

F. Sakao & R. Conroy 2013 医科問診票 ページ１

Allergies アレルギー
Have you ever been allergic to anything? (medicine, food, other) アレルギーの有無（薬、食べ物、他）
No
Yes
What? 何にHave you had side effects caused by medicine? 薬の副作用の有無
No
Yes
Which medicine? 薬名Have you had problems after having a local or general anesthetic? 全身又は局所麻酔歴No
Yes
What? 何にQuestions for Women 女性への質問
Are you pregnant? 妊娠していますかNo
Yes
Not sure
わからない
Are you currently breastfeeding? 今、授乳中ですかNo
Yes
Are you taking contraceptive pills? 今、避妊用のピルを服用してますかNo
Yes

Medication 薬
Are you currently taking any prescribed or over-the-counter medicine(s)? 今、処方薬又は売薬を服用していますかNo
Yes
Which medicine(s)? 何の薬をBufferin
Aspirin
Warfarin ('Coumadin,' 'Warfilone,' 'Marevan')
Other: Please write the medicine name(s). 薬名を具体的に書いて下さい
Why are you taking it/them? 何の為Alcohol and Tobacco お酒とタバコ
Do you regularly drink alcohol? お酒を定期的に飲みますかNo
Yes
How much in 1 week? 週にどのくらい？
Do you smoke? タバコは吸いますかNoYes
How many a day? 一日に本

Did you smoke before? 以前に吸ったことありますかNo
Yes
How many a day? 一日に本

1 beer (500ml)

1 glass of wine

1 measureof spirits

ビール５００ｍｌ

グラスワインリキュール

How long have you smoked? どのくらいWhen did you stop? いつやめましたか

Other: その他

months ヶ月間

years 年間

months ago ヶ月前

years ago 年前Treatment Preferences and Medical Fees 治療の希望と医療費
Do you have Japanese Health Insurance or private medical insurance? 日本の保険証又は他の私的医療保険証をお持ちですかNo
Yes
Do you only want treatment for your main problem? 現在困っている問題の治療のみ希望しますかNo
Yes
Not sure
わからない

Please return this form. Thank you.

F. Sakao & R. Conroy 2013 医科問診票 ページ２