Breast Center QuestionnaireThis Questionnaire contains important information for the medical care you receive at
this hospital. Please answer in detail, independent of the content of the reference letter.
Ageyears

DateMMDD, YYYY

Do you undergo breast cancer checkups regularly?
□YES□NO□Other ()If you answered YES: From the age of ____years, every ____years; □Mammography □Ultrasound □Alternating □Only Palpation
How did you find the present abnormality? □Breast cancer check-up □Subjective symptoms □Other ()Tests undergone at another hospital:□Mammography □Ultrasound □MRI □Cyst Aspiration □Needle Biopsy □Surgery □OtherSubjective Symptoms □Absent □Present (□Lump□Pain (No pain:0 1 2 3 4 5 6 7 8 9 10:Worst possible pain) □Nipple Discharge□Others ()Have you received a diagnosis of definite/suspected breast cancer at another medical institution?
□YES □NO
Are you currently receiving treatment for breast cancer at another medical institution?
□YES□NO
Please describe the course of your current breast problem in detail.

Contact: Phone no.：（）－□Home □Mobile (□Your own □Someone else（）) □Work □Other（Another phone no.：（）－□Home □Mobile (□Your own □Someone else（）) □Work □Other（Can we leave a message from the hospital with your family? □YES □NO
Please give us an address where we can send you letters, including your test results, from the Breast Center.
Address:））If you have an appointment within the next 3 months, we will return the X-ray films, CD-R, etc. from the other medical institution to you at the that time.

If you do not have a scheduled appointment, can we send these to your home?
□YES□NOIf you have answered NO, we will return these materials to the medical institution that referred you. If these do not have to be returned,
we will responsibly dispose of them at this hospital.

Medical History Please fill out the following information concerning diseases you experienced and surgical operations you underwent.
Hypertension
Diabetes
AsthmaGlaucoma
OthersHistory ofPsychosomatic
Medicine
consultations

□NO
□NO
□NO
□NO
(Age: years) ((Age: years) (□YES: □Under treatment□YES: □Under treatment□YES: □Under treatment□YES: □Under treatment□NO(Age□YESyears:□Treatment terminated□Treatment terminatedInsulin usage: □NO(Last attack: MY)□Treatment terminated); (Age: years) (); (Age: years) (History of taking sleeping□NOpills/anti-anxiety agents）□YES

Mark the number representing the average extent of negative feelings you

Negative feelings experienced over the last week with a circle (〇).

To what extent did your negative feelings interfere with your daily life activities?

Allergies□NOSurgery□NOSmoking□NOAlcohol□NOCovid-19 vaccinations□NO□YES:□Medications （□YES (Ageyears:□YES () cigarettes/day for (□YES () amount / day; type: (□YES
Last vaccination ( MMInfluenza vaccination□YES□NO( MM(Age□YES))

years:

No negative feelings:0 1 2 3 4 5 6 7 8 9 10: Extreme negative feelings
No interference:0 1 2 3 4 5 6 7 8 9 10: Severe interference） □Metal （） □Others (）; （Ageyears:）) years ; () years since quitting） for () years; () years since quittingDD）

DD, YY) / (Left, YY) / (Left/ Right））/ Right）

Please also fill out the back.
〒104-8560 東京都中央区明石町 9 番 1 号 Tel.03-3541-5151 Fax. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.

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Gynecology History
Menstruation
Pregnancy/Delivery
Gynecological
Diseases
Breastfeeding History
Infertility Treatment

First menstruation (age: years); Period:□Regular □Irregular □Menopause ( years)□Artificial menopause ( years)
First day of last menstrual cycle: M
D, Y
Menstruation cycle:days
Delivery:times □Pregnant now: weeks days □May be pregnantPregnancy:□NO□YES □Uterine myoma(Surgery: □NO □YES, procedure:□Endometriosis□Ovarian cyst
(Surgery: □NO □YES, procedure:□Other:(Surgery: □NO □YES, procedure:□NO□Currently breastfeeding□YES□NO□YES (When?:/Which?:
How many times?:

History of hormone replacement therapy: □NO□YES (When?

/What?

/How long?:)))））

Please list all medications you are currently taking, and bring your Medication Notebook along.
Oral medications/Supplements□NO □YES: Name(s) of the drug(s):Family History (Blood relatives, up to cousins on both the father’s
Family structureand mother’ sides)
Include age at the time of onset of the disease and therapy
Spouse□Yes:
years
Occupation:■ Breast/Ovarian cancer □Yes □No□Widowed□Unmarried□Divorced
Partner□Yes □No
Siblings/Children：
Mother, maternal relatives：

Own father：years □Died □Lives together □Lives separately

Father, paternal relatives：
Own motheryears □Died □Lives together □Lives separately
Other kinds of cancer□Yes □No
Children (Age/Living together or not)
 Siblings/Children：
Mother, maternal relatives：
Father, paternal relatives：
Own siblings (Age/Living together or not)Other diseases than cancer□Yes □No Siblings/Children：
People providing support to you:
Mother, maternal relatives：
Father, paternal relatives：
Occupation
We support you with your work and career while you undergo treatment. Please ask the staff for more information.
Employment□ Unemployed□ Employed
Field of work:
Employment Status □ Freelance□ Full-time□ Contract Employee□ Part-timeSpecific Job Description：
You can have a consultation about employment matters. Do you wish to have such a consultation? □YES □NO
Do you have a boss or industrial physician at work whom you trust and can consult with? □ YES□ NO□ I’m not sure
Working arrangements: Nighttime shifts □YES □NO Flex-time/reduced schedule □YES □NO Business Trips □YES □NOOff days:

days /week on ()day / ()day/()day

Holiday system□YES□NOOthers
Many patients who have children find it hard to explain their disease to their children. At St. Luke’s International Hospital, a child support team isavailable to advise you. Do you wish to have a consultation with the child support team?
□YES □NO
For those considering pregnancy/delivery, we offer treatment in collaboration with the Integrated Women’s Health Clinic
Do you wish to have a consultation at the Integrated Women’s Health Clinic? □YES□NOAt this hospital, patients are treated with blood transfusion when deemed medically necessary.
Do you agree to undergo blood transfusion in the event that it becomes medically necessary? □YES
□NO【For patients over 65 years】 Have you applied for long-term care insurance?
□Yes, I applied: Require assistance (); Require nursing care (); □Under application (When?
）; □Not applied; □Unsure
230814_Ver10.00_A4 白黒両面

〒104-8560 東京都中央区明石町 9 番 1 号 Tel.03-3541-5151 Fax. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.

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