Preliminary Diagnosis List(予診票)
Outpatient of Obstetrics and Gynecology(産婦人科)
DATE:

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Your name:Date of birth:

Occupation(職業):

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Years oldCountry of Citizenship(国籍):＿＿＿＿＿＿＿＿＿Name of your husband or partner:

Date of birth:

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Years old

Occupation(職業):＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿ Country of Citizenship(国籍):＿＿＿＿＿＿＿＿＿Your home address:＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
Phone number:＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿Height(身長):kg

cm Weight(体重):Please make a circle on item for the reason for today’s visit.(本日来院した理由に〇をつけてください)
Introduction from the hospital(病院からの紹介):＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿
Anxious about UTERUS MYOMA(子宮筋腫) /血圧測定用紙貼付

Cancer screening(がん検診) / DISCHARGE(おりもの) /ITCHING(かゆみ) / IRREGULARITY OF PERIODS(月経不順) /BLEEDINNG FROM THE GENITALS(不正出血) / pregnancy(妊娠)Other reason:＿＿＿＿＿＿＿＿＿＿＿＿＿＿＿

尿蛋白(About menstruation(月経について)・What was tour age of the monarch(月経が初めて来たのは何歳ですか)?:・Menstrual cycle by every(月経周期);
Earliest cycle(早いとき);)糖()ケトン()

years olddays,days, Latest cycle(遅いとき);・Duration of bleeding(月経の出血は何日間か) : fordays.

days.

・Amount of bleeding(出血量は) : little(少) / medium(中) / plenty of(多)・Menorrhagia(生理痛は) : Yes / No.
If yes : Pain in abdomen(下腹部痛) / Lumbago(腰痛) / Taking medicine(内服) / Going to bed(寝ている) /Others(その他)＿＿＿＿＿＿＿＿＿.
・Date of the latest periods(最近の月経);

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for

・Date of the periods prior to the above latest periods(その前の月経);
・What was your age of menopause(閉経)?:

day’s bleeding.
//forday’s bleeding.

years old.

About marriage(結婚について)Your age at your marriage(結婚年齢);

years old. Its dateNot being married(未婚) / living together(同棲中)(from when)
Divorce(離婚);//(year/month)/(year/month)(year/month)

Do you have sexual intercourse(性交渉の有無)? ; Yes / No
About life(生活について)
Do you smoke(タバコ)；Yes:

per day(1 日あたり) /No

Do you drink alcohol(飲酒); Yes:

per day / Sometimes(時々) :Is there an ongoing religion(進行している宗教はありますか)? Yes:

days a week (週に)/ No/ NoAbout pregnancy and childbirth(妊娠・出産について)※If you are pregnant, please enter the number of times including this pregnancy(今回の妊娠を含めた回数).
Pregnancy(妊娠)：
Abortion(流産).;

times, Delivery(分娩).:

times, Caesarean section(帝王切開):No/ Yes(times, Artificial abortion(人工中絶).:

Ectopic pregnancy(子宮外妊娠).:times)

times,times, Hydatidiform mole(胞状奇胎).:

times

Please fulfill this list in order of pregnancy(以下は妊娠した順番に記入してください).
Date(year/month)Months of

Course of pregnancy/delivery

pregnancy(妊娠、分娩経過)WeightSexdelivery(妊娠週数)
1/

Place of(分娩場所)

Abortion(自然流産) /Male /Artificial abortion(人工中絶) /gFemalegMale /

Normal delivery(正常分娩) /
Weeks
2/

Abortion / Artificial abortion /
Weeks

3/

Normal delivery / Abnormal

FemaleAbortion / Artificial abortion /Weeks

4Abnormal(異常)/g

Normal delivery / Abnormal

FemaleAbortion / Artificial abortion /Weeks

Male /g

Normal delivery / Abnormal

Male /
FemaleAbout the condition of the body(体の状態について)
Do you have any allergies? (アレルギーはありますか) :Yes / No
If yes; Food(食物) / Drug(薬剤) / Animal(動物) / Plant(植物) / Rubber product(ゴム製品) / Hay fever(花粉症)
Specifically(具体的に):Have you ever had the following illnesses? (次のような病気にかかったことはありますか): Yes / No
Liver(肝臓) / Kidney(腎臓) / Heart(心臓) / Allergy(アレルギー) / Tubercle(結核) / Venereal disease(性病) /Diabetes(糖尿病) / High blood pressure(高血圧) / Caecum(盲腸) / Others:
years old

Disperse name;

The name of the hospital;

years old

Disperse name;

The name of the hospital;

If you have undergone any operation, please fulfill the name of disease and its date(year/month).: Yes / No
(手術をしたことがある場合にはその病名と年齢を教えてください)
years old

Disperse name;years old

Disperse name;Is there any medicine you are taking now? (今飲んでいるお薬はありますか)；Yes / No
If yes, be specific:
About vaccination of new coronavirus(新型コロナウイルスのワクチン接種について)
Inoculated(接種した):First time ://Will be inoculated in the future(接種する予定) :,Second time:
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,Third time:/

Not inoculated(接種していない)/