□Consultation 診察済 □Register 入力済 □Referral Letter 紹介状有WOMEN‘S HEALTH MEDICAL HISTORY QUESTIONNAIRE
Name：

HeightDate of Birth：/cm

Weight/kg

1. Reason for your visit today□Abnormality of Menstruation (□Absent menstruation □Irregular cycle □Heavy bleeding □Severe cramps □Others )□Abdominal or back pain unrelated to menstruation□Any bleeding or spotting between menstrual cycles□Re-examination after medical checkup (specify:)□Abnormal vaginal discharge / genital abnormality (□Heavy/colored □Irritation □Pain □Lump)□Menopausal concerns□Birth control consultation□Others (specify:)
2. Menstrual History
 Age of the first period Recent period started on
 Previous period started on Menstrual Cycle Regular:

years old・In menopause →Age of menopause//
fordays//fordaysdays （Shortest:days, Longest:years olddays）

3. History of sexual intercourse, pregnancy and labor(If you do not wish to answer, please tell your physician directly.)
・Have you ever had sexual intercourse?
□No □Yes
・Have you ever been pregnant?
□No□Yes If yes, specify: □Normal delivery times □Caesarean section times□Miscarriage times □Abortion times □Ectopic pregnancy times□Trophoblastic disease times
4. Past Medical History
 Have you ever had any illnesses?

□ No□Yes If yes, specify：□Hypertension □Diabetics □Asthma□Others
 Have you ever had any surgeries? □ No
□Yes If yes, specify:
Age:Type of Surgery:
Age:
Type of Surgery: Are you currently under treatment? □ No
□ Yes If yes, specify: □Hypertension □Diabetics □Asthma □Others
・Are you currently taking any medications (Including supplements) ?
□ No□ Yes If yes, specify: all medications
 Do you have allergies to any medications or food?
□No□Yes If yes, specify medications
Others〒100-0004 東京都千代田区大手町一丁目 9 番 7 号 大手町フィナンシャルシティ サウスタワー2 階Tel.03-3527-9520 Fax. 03-3281-5630
Copyright © St. Luke's MediLocus 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.

5. Social History
 Do you smoke cigarettes now? □Never□Former □Current How many?
cigarettes/day How long?
 Do you drink alcohol?
□No□Yes What kind/How many?
/ml/day Do you have any religions or cultural practices that are important to you during this hospitalization?
□ No□ Yes If yes, please describe

years

6.Please circle the below number that best averages how emotionally stressed the past week has been for you.
Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely
7.To what extent did your emotional stress interfere with your daily life activities?
Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely
8. At St. Luke's International Hospital, patients are treated with blood transfusion when deemed medically necessary.
Do you agree to undergo blood transfusion?
□ Yes □ No
9. Family History
 Father: Age□Healthy □Illness
 Mother: Age□Healthy □Illness
Brothers/sisuters,grandparents,etc.
() Age□Healthy □Illness
() Age□Healthy □Illness□Deceased Age□Deceased Age

Cause of death
Cause of death□Deceased Age□Deceased Age

Cause of death
Cause of death

10. Your contact information.
Address:Phone:(Cell phone ・ Home ・ Work)* Would you mind mentioning the name of the hospital when we make a call?
□Yes □No
11.How did you hear about us?
□Posters/pamphlets□HP□St. Luke's International Hospital □Another medical institution□Place of employment introduced □Family/friends introduced□Others（）*We may use and disclose your health information on a de-identified basis for research purposes. We appreciate
your support and understanding.

2023.9.8-Ver.4.00-A4 白黒両面

〒100-0004 東京都千代田区大手町一丁目 9 番 7 号 大手町フィナンシャルシティ サウスタワー2 階Tel.03-3527-9520 Fax. 03-3281-5630
Copyright © St. Luke's MediLocus 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.