Patients Visiting the Urology Outpatient Clinic
Name：＜Questionnaire＞

Patient ID：

Age：

Telephone number (A number the hospital can call when necessary):

1. Please explain your symptoms in detail (when, where, how).

Are you in pain?

( YESNO )For those who have answered yes, please specify.
0No pain

12345678910
Most severe pain

2. Please fill out the age when you had the following diseases, and how it was treated.
DiseaseTreatment

Asthma(Age:)

Admission ・ Surgery ・ OtherDiabetes(Age:)

Admission ・ Surgery ・ OtherHigh blood pressure(Age:)

Admission ・ Surgery ・ Other

Glaucoma(Age:)

Admission ・ Surgery ・ Other

Cardiac disease(Age:)

Admission ・ Surgery ・ Other

Liver disease(Age:)

Admission ・ Surgery ・ Other

Kidney disease(Age:)

Admission ・ Surgery ・ Other

Cerebrovascular disease(Age:)

Admission ・ Surgery ・ Other

Psychiatric disease(Age:)

Admission ・ Surgery ・ OtherCancer(Age:)

Admission ・ Surgery ・ Other

Hemorrhoid(Age:)

Admission ・ Surgery ・ Other

3. Please circle the diseases below which any of your blood relatives have had.
Asthma ・ Liver disease ・ Kidney disease ・Cardiac disease ・High blood pressure ・Cerebrovascular disease ・Psychiatric disease ・Cancer
4. List any allergies you have.
Medication （）Food（）Other（）5. List any regular medications you take.

6. If you have had blood transfusion before, please fill out the age when you had it.

(Age:)

7. At St. Luke's International Hospital, patients are treated with blood transfusion when deemed medically necessary.
Do you agree to undergo blood transfusion?

( YESNO )8. Personal preferences

Cigarette: Non-smoker・Smoker (Alcohol: Sake ・Shochu (__glasses/day)cigs/day xyrs.)・Quit (smoked until __yrs. __months ago,Beer (___ml/day)cigs/day xyrs.)

Liquor (___glasses/day)* Please also fill out the questionnaire on the back
TEL: .03-3541-5151 FAX:. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.

9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560 JAPAN①Mark the average extent to which you have been feeling emotionally stressed the past week expressed as a number?
0123456789Not at all②Extremely

How much has the emotional stress you felt interfered with your activities of daily life expressed as a number?
0123456789Not at all③1010Extremely

Over the past 2 weeks, how often have you been troubled by the following problems?
Never

A coupleof days

More thanhalf of thetime

Almostevery day（Ａ） Almost nothing interests me and I cannot enjoy anything.

□□□□（Ｂ） I feel down, depressed, and hopeless.

□□□□（Ｃ） I cannot fall asleep, wake up during the night, or sleep too long.

□□□□（Ｄ） I feel tired and have no strength.

□□□□（Ｅ） I have no appetite or eat too much.

□□□

□

□□□

□

□□□

□

□□□

□

□

□

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（Ｆ） I feel like I am no good, a loser, and as if I am causing trouble formy family and myself.
（Ｇ） I cannot concentrate on reading the newspaper or watching TV.
（Ｈ） I move or talk so slowly that other people notice it, or on the other
hand I am moving around restlessly and fidgeting.
（I） I have thought that it would be better to be dead, or tried to injure
myself in some way.

230609_Ver.3.00_A4 白黒両面

TEL: .03-3541-5151 FAX:. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.

9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560 JAPAN