心臓検診問診票（英語）School Heart Examination Inquiry
Dear parents/guardians,
In order for the children to have a fun and meaningful school life, we would like to ask foryour cooperation in providing information on your child's heath. This inquiry is intended
for medical purpose, to examine the state of the heart examination, which is deemed
important. If there are questions, please do not hesitate to contact either theschoolteachers or any doctors.
We request that information be filled as accurately as possible.
GradeClass

NumberChild's Name

Question 1: Until now, have there been any heart problems, such as unusual heartbeat,arrhythmia, and unusual electrocardiogram?
1) Yes2) No※ If the answer is yes, please answer the following questions:
A When and where was the unusual heart symptom? age
2. medical examination in(1. name of hospital

grade)

B What was said about the nature of the unusual symptom? Please circle.
1) heart disease from birth(name of disease2) heart valve(name of disease3) heart contraction(name of disease4) heart enlargement(name of disease5) arrhythmia (swollen heart)(name of disease6) unusual electrocardiogram(name of disease7) heartbeat (unclear)(name of disease8) chest pain related to rheumatism
9) others(name of disease10) details unknown
C Please circle any of the tests that your child has undergone.
l) electrocardiogram 2) supersonic test (heart echo) 3) exercise test5) catheterization test))))))))

4)

cardiacDl)

What happened after the test?
diagnosed with heart problem after close examination
name of hospital(age)2) heart surgery (agename of hospital)
3) regular hospital visits due to routine medical checkup or medical treatment
name of hospital(age)4) despite the doctor's advice for necessary medical treatment, no action was taken5) nothing6) the unusual symptom was cured
name of hospital(age)7) according to the doctor, there was no need for medical treatment
name of hospital(age)8) others ()Question 2: Until now, has a doctor ever doubted whether your child had Kawasaki
Disease (fever exceeding 39 degrees and lasting 1 to 2 weeks)?
1) Yes2) No*If the answer is yes, please answer the following questions:A When and where was the disease diagnosed? age ______
2. medical examination in(1. name of hospital
What kind of medical treatment was undertaken?
1)
aspirin treatment 2)
gamma globulin treatment
4)
others5)
unknowngrade)

BCl)

3)

steroid treatment

With Kawasaki Disease, were there any difficulties with the heart?
Yes (1. one day 2. continuously 3. unknown) 2)
NoD Until now, which test has been undertaken? Please circle those that apply.
l)electrocardiogram test 2) supersonic test (heart echo)3)exercise test4) cardiac catheterization & coronary angiography's test (inserting a catheter into acoronary artery and put contrast media into it to check)El)

What happened after the test?
regular hospital visits due to routine medical checkup or medical treatment
name of hospital(age)2) despite the doctor's advice for necessary medical treatment, no action was taken3) nothing4) according to the doctor, there was no need for medical treatment
name of hospital(age)5) others ()Question 3: Until now, has any of the following applied?
A Feeling painful and feeling an urge to rest after even a light exercise
1)
Yes
2)
NoB The pulse occasionally paused
1)
Yes
2)
NoC The pulse sudden became faster, about twice the normal rate
1)
Yes
2)
No
* If the answer is yes, please answer the following questions:1) The pulse at that time was (1. irregular 2. regular), about ___ times per
minute and lasted about ___ (seconds, minutes, hours) continuously
2) Were there any symptoms of chest pain or cold sweat? 1. Yes
2. No
D While exercising, there was a contraction in the chest1) Yes2)
No*If the answer is yes, please answer the following questions:1)What kind of exercise was it?
2)How continuous was the exercise? aboutminutes
seconds3)While exercising, chest pain takes place?
1. certainly
2. sometimes ( __times per month, __ times per year)
E Has your child ever passed out (excluding obvious causes such as traffic accident)?
1) Yes2) No*If the answer is yes, please answer the following questions:
1) passing out after enduring a long period of time and becoming sick2) passing out after a bath or going to the restroom3) passing out abruptly while
4) others
Question 4: Has there been any sudden death of a family member or relative under theage of 40 as a result of heart disease (excluding accident-related deaths)?
1)
Yes
2)
No
Please read it well , and write it down properly. (よく読んで正しくご記入ください。)
Bring an inspection in school by themonthday.
(用紙を＿月＿日までに学校に持ってきてください。)