Breast Surgery Medical QuestionnaireThis Questionnaire contains important information for the medical care you receive at
this hospital. Please answer in detail, independent from the reference letter.

NameAge

Date of BirthConsultation Dateyears

MM

DD,Y,YDo 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 other hospital:□Mammography □Ultrasound □MRI □Cyst Aspiration □Needle Biopsy □Surgery □Other
Subjective Symptoms □Absent □Present (□Lump□Pain□Nipple Discharge □Other ()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.

 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:

Hypertension

Please fill out the following medical/surgical and other information concerning diseases you had andsurgical operations you underwent.
□NO□YES: □Under treatment □Treatment terminatedDiabetes□NO□YES: □Under treatment□Treatment terminatedInsulin usage:□NOAsthma□NO□YES: □Under treatment(Last attack: M)Glaucoma□NO□YES: □Under treatment

Medical HistoryOthers
History ofPsychosomaticMedicine□YES□Treatment terminated(Age: years) ();(Age: years) ()(Age: years) ();(Age: years) ()History of taking sleeping

□NO

□NO

pills/anti-anxiety agents□YES(AgeAllergies□NO□YES:□Medications （Surgery□NO□YES (AgeSmoking□NO□YES () cigarettes/day for (Alcohol□NO□YES () amount / day; type: (consultationsY）

years:）(Age□YES） □Others (） □Metal （years:）; （Age) years ;） for ((years:）））) years since quitting) years; () years since quitting
Please see back

〒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.

1/2years:

Gynecology History
Menstruation

First menstruation (age:years); Period:□Regular □Irregular □Menopause ( years)□Artificial menopause (years)

First day of last menstrual cycle: M
Pregnancy/Delivery

DPregnancy:
Delivery:
回times□YES□Uterinemyoma□NO□Endometriosis□Ovarian cyst
□Other:GynecologicalDiseases, Ydays□Pregnant now: weeks days □May be pregnant(Surgery: □NO □YES, procedure:(Surgery: □NO(Surgery: □NO

Breastfeeding History□NO□Currently breastfeeding□YES

Infertility Treatment□NO□YES (When?:/What?:

History of hormone replacement therapy: □NO

Menstruation cycle:□YES (When?

□YES, procedure:□YES, procedure:))

How many times?:/What?

)/How long?:））

Note down 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 andFamily structuremother’ 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
Siblings/Children：

PartnerMother, 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

□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：

Mother, maternal relatives：

People providing support to you:

Father, paternal relatives：
Occupation
Employment

We support you with your work and career while you undergo treatment. Please ask the staff for more information.
□ Unemployed

Employment Status □ Freelance□ Employed

Field of work:□ Full-time□ Contract Employee□ Part-timeSpecific Job Description：
Do you have a boss or industrial physician at work that you can trust and talk to? □ YES□ NO□ I’m NOT sure

Working arrangements: Nighttime shifts □YES □NO Flex-time/reduced schedule □YES □NO Business Trips □YES □NO
Holiday system:

days/week on ()day / ()day/()day/ Other holiday system□YES□NOOthers【For patients over 65 years】 Have you applied for long-term care insurance?
□Yes, I have applied: Require assistance (); Require nursing care () □Under application (when?
） □Not applied
Many patients who have children find it hard to explain their disease to their children. At St. Luke’s International Hospital, a child life specialist isavailable to advise you. Do you wish to have a consultation with the child life specialist?
□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
□NO220127_Ver.9.00_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.

2/2