WOMEN‘S HEALTH MEDICAL HISTORY QUESTIONNAIRE
Name：

HeightDate of Birth：/cm

Weight/kg

1. 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
2. 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:)
3. 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:

4. Do you have allergies to any medications or food?
□No□Yes If yes, specify medications

days）

Others

5. 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□Miscarriage times □Abortion□Trophoblastic disease times
6. Family History
・Father: Age□Healthy □Illness
・Mother: Age□Healthy □Illness
Brothers/sisuters,grandparents,etc.
・() Age□Healthy □Illness
・() Age□Healthy □Illness

years oldtimes □Caesarean section
times □Ectopic pregnancy□Deceased Age□Deceased Age

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

Cause of death
Cause of deathtimestimes〒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.

7. 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
8. 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 describeyears

9. 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
10. 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
11. 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
12. 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.

2023.12.5-Ver.5.00-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.