Medical History Form
既往歴
Date 日付: ______________Name 名前: __________________________________________________ Age 年齢: ____ Date of Birth 生年月日: ______________
Reason for visit today 疾病又は障害の内容:________________________________________________________________________________________________________________________________________________________________________________________________________________________
Current and past medical problems (conditions and dates of diagnosis) 治療中・過去の病気(病名・年):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Current medications and doses (prescribed, non-prescribed, herbal) 服用している薬、漢方、健康食品、ビタミン:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies (to medications/latex/food) アレルギー(薬・食べ物・ゴム): Yes/No ___________________________________________
Past hospitalizations (conditions and dates and hospital) 入院(病名・年・病院名):________________________________________________________________________________________________________________________________________________________________________________________________________________________
Past surgeries (conditions and dates and hospital) 手術(病名・年・病院名):________________________________________________________________________________________________________________________________________________________________________________________________________________________
Significant injuries 事故・怪我: __________________________________________________________________________________
Current/recent healthcare providers (specialty and hospital) 現在かかっている担当医・専門医(病院名):________________________________________________________________________________________________________________________________________________________________________________________________________________________
Family history : (father, mother, siblings, paternal/maternal grandparents) 家族暦(父・母・兄妹・祖父・祖母)
Relatiionship and age of diagnosis (関係と診断された年齢)
Cancer (type) 癌(病名) : __________________________________________________________________________
Heart disease/stroke 心臓病・脳梗塞: __________________________________________________________________________
Diabetes 糖尿病:__________________________________________________________________________
Mental disease/addiction 精神病・依存: __________________________________________________________________________
Asthma/eczema 喘息・アトピー: __________________________________________________________________________
Other その他: __________________________________________________________________________
Current household members (any pets?) 同居者(ペット込み):_________________________________________________________
Occupation/school (any safety hazards?) 職業・学校(職業上・学校内の危):________________________________________________________________________________________________________________________________________________________________________________________________________________________
Smoking 喫煙:Y/N 有・無Current/past 現・過 _____ Packs/day for _____ Yrs 1 日_____ 箱を_____ 年間
Alcohol アルコール:
Y/N 有・無__ Drinks of ________ per day/wk/mth 種類_____ 1 回の量_____週に何回_____
Drugs ドラッグ:
Y/N 有・無Current/past 現・過 Type 種類: _______________________________________
Exercise/sports 運動・スポーツ: Y/N 有・無_____ min/hr per day _____ days per wk/mth 1 回 _____ 分を週に_____ 回
Sleep 睡眠: ___ hr 時間 Difficulty falling asleep 寝つき Y/N 良･悪 Difficulty maintaining sleep Y/N 浅い･深い Difficulty waking up
寝起き Y/N 良･悪Happiness level 幸せ度: 1 Least happy 最小 2 3 4 5 6 7 8 9 10 Most happy 最大(Circle one○して下さい)
Stress level ストレス度: 1 Least stressed 最小 2 3 4 5 6 7 8 9 10 Most stressed 最大(Circle one○して下さい)
Last checkup (mo/yr) 健康診断受診日(月年): ____________________ Pap/mammo (mo/yr) 婦人科検診日: ___________________
Colonoscopy (mo/yr) 内視鏡検査受診日(月年): __________________ 過去にピロリ菌治療: 有・無Vaccines in the last 10 years (type and mo/yr) 過去 10 年に受けた予防接種(種類・月年):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Last menstrual period 最終月経日: _________

Do you have these problems currently or recently (few weeks)?
現在や最近（数週間）に症状はありますか？
Please circle.
Constitutional
Fatigue
Fevers/Chills
Night sweats
Abnormal weight gain/loss
Other〇して下さい。
体質
疲労
熱・悪寒
寝汗
体重の変動
その他

Eyes
Blurry vision
Eye pain
Other

目
かすみ目
痛み
その他

Ear, Nose, and Throat
Hearing loss
Ringing of the ears
VertigoRunny nose
Nose bleeds
Sore throat
Voice change
Other

耳鼻喉
難聴
耳鳴り
めまい
鼻水
鼻血
喉の痛み
声の変化
その他

Name 名前:
Date 日付:Musculoskeletal
Joint Pain
Back PainProblem Walking
Other

筋肉や関節関節痛
腰痛
歩行の問題
その他

SkinRashChange in Mole
Other

皮膚発疹
ほくろの変化その他

Neurologic
Seizures
StrokeHeadaches
WeaknessNumbness/Tingling
Other

神経痙攣（けいれん）
脳梗塞・脳卒中
頭痛
虚弱・脱力感麻痺・しびれその他

PsychiatricDepression
Anxiety
Cardiovascular
心血管
Suicidal thoughts
Chest pain
胸痛
Difficulty sleeping
Swelling of feet
むくみ
Other
Diffuculty breathing when lying down flat
平らだと息苦しい・枕の数が増えた
Palpitations or irregular heartbeat
動悸・不整脈Endocrine
Heart murmur
心雑音Heat/Cold intolerance
Other
その他
Change in skin or hair
Excessive thirst or urinationRespiratory
呼吸
OtherCough咳
Shortness of breath
息切れ
Hematologic/Lymphatic
Asthma
喘息（ぜんそく）Easy bruising
COPD
慢性閉塞性肺疾患
AnemiaOther
その他
Swollen lymph nodes
Other
Gastrointestinal
消化Nausea/Vomiting
吐き気
Men Only
Diarrhea/Constipation
下痢・便秘Difficulty with erection
Bleeding
血便・潜血Weak urinary stream
Other
その他
Other
Genitourinary
Burning with urination
Frequent urination
Discharge
Other

泌尿痛み
頻尿
おりものその他

None of the above

上記該当なしWomen Only
Change in periods
Vaginal discharge
Nipple discharge
Breast lumps
Other

精神うつ病不安症
自殺願望
不眠症
その他
内分泌
暑がり・寒がり皮膚や髪の変化喉の渇き・多尿その他
血液・リンパ腺
あざができやすい
貧血
リンパ腺の炎症その他
男性
勃起障害
尿の勢いが少ない
その他
女性
生理の変化
おりもの乳汁胸のしこりその他