WOMEN’S HEALTH MEDICAL HISTORY QUESTIONNAIRE(Department of Integrated Women’s Health)*Please fill in the below with a red pen and submit it to the receptionist.
Name:

Patient ID Number:

Date of Birth:Age:.

Address:
Phone Number:(Home / Cell)*May we mention this hospital’s name when we call? (☐ Yes ☐ No)
Nationality:
Occupation:
Height:cm Weight:kg

1. Please tell us the purpose of your visit today. *Please inquire with our Breast Center for matters regarding

your breasts.

☐ I wish to deliver my baby here (Due date: _______________________ / Undecided)☐ Menstrual abnormalities → ☐ Never menstruated ☐ Menstruation stopped over time ☐ Irregular menstruation☐ Heavy menstruation ☐ Light menstruation ☐ Strong pain

☐ Irregular bleeding ☐ Abdominal pain ☐ Lower back pain ☐ Abnormal discharge (☐ Large amount ☐ Colored☐ Off-smelling)☐ Fibroids ☐Ovarian cystoma ☐Endometriosis ☐ Genital abnormalities ☐ Possible cancer☐ Lowered uterus ☐ Test for sexually-transmitted infections ☐ I want to have children☐ Consultation on contraceptives☐ Menopausal symptoms (Specific symptoms: _________________________________________________) ☐Request for test → ☐ Instructed for further screening (☐ Cervical cancer screening ☐ Endometrial cancerscreening ☐ Other: ________________________________)☐ I want a prenatal test; I’m worried about genetic or hereditary abnormalities☐Other/I want to discuss my progress or other matters

2. Please tell us about your menstruation.
First period: Around ______ years old Menopause: Around ______ years old
Most recent period: Started on (YYYY)______(MM)_____(DD)_____ and lasted ______ days
Menstrual cycle (Number of days from the day your period starts until the day your next period starts):______ -day cycle / Lasts _____ days
When early, it comes around the (DD)_____. When late, it comes around the (DD)_____. (Regular / Irregular)
Pain (severe / mild / none) Amount (heavy / normal / light)

9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560 JAPAN; Tel.: 03-3541-5151 Fax.: 03-3544-0649

Copyright © St. Luke's International Hospital All rights reserved
This English translation is true to the original Japanese, but serves as a reference, while the Japaneseversion is the official version that has legal effect and takes precedence in the event of any conflict.

1 /4

3. Do you have any allergies? ☐ No ☐ Yes
Medication: ____________________________ Foods: ______________________________
Other (Latex, pollen, etc.): ____________________________________________
What symptoms did you develop and at around what age? _________________________________________
4. Please tell us about your pregnancy/childbirth history.

*Have you ever had sexual intercourse? ☐ Yes ☐ No *Have you ever been pregnant? ☐ Yes ☐ NoWeeks atgestation
during birthYear and outcome of pastbirths/miscarriages
YearYearYearYear

Year

Normal/preterm/
miscarriage/abortion/ectopic pregnancy/Molar
pregnancy
Normal/preterm/
miscarriage/abortion/ectopic pregnancy/Molar
pregnancy
Normal/preterm/
miscarriage/abortion/ectopic pregnancy/Molar
pregnancy
Normal/preterm/miscarriage/abortion/ectopic pregnancy/Molar
pregnancy
Normal/preterm/
miscarriage/abortion/ectopic pregnancy/Molar
pregnancy____weeks____weeks____weeks____weeks____weeks

Delivery method

Complications

ChildrenVaginalNo

Weight at birth: ____ g(Epidural/vacuum/forceps)

Yes

Sex: M / F

Caesarean section(___________

Past/Current Illnesses:(Reason:___________)____________________

VaginalNo

Weight at birth: ____ g(Epidural/vacuum/forceps)

Yes

Sex: M / F

Caesarean section(___________

Past/Current Illnesses:(Reason:___________)____________________

VaginalNo

Weight at birth: ____ g(Epidural/vacuum/forceps)

Yes

Sex: M / F

Caesarean section(___________

Past/Current Illnesses:(Reason:___________)____________________

VaginalNo

Weight at birth: ____ g(Epidural/vacuum/forceps)

Yes

Sex: M / F

Caesarean section(___________

Past/Current Illnesses:(Reason:___________)____________________

VaginalNo

Weight at birth: ____ g(Epidural/vacuum/forceps)

Yes

Sex: M / F

Caesarean section(___________

Past/Current Illnesses:(Reason:___________)____________________)))))

9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560 JAPAN; Tel.: 03-3541-5151 Fax.: 03-3544-0649

Copyright © St. Luke's International Hospital All rights reserved
This English translation is true to the original Japanese, but serves as a reference, while the Japaneseversion is the official version that has legal effect and takes precedence in the event of any conflict.

2 /4

5. Please tell us about your partner and your family (excluding your children).
*Please include information regarding hypertension, diabetes, cancer, mental illness, and sudden death.
☐ Not married ☐ To be married soon ☐ Married (Month _____Year: ______ Age: ____)☐ Divorced (Year: ______ Age: ____) ☐ Widowed (Year: ______ Age: ____)☐ Remarried (Month _____Year: ______ Age: ____)

Partner: ____ years old (Nationality: _________________) (Occupation: ________________) ☐ Healthy☐ Ill (Name of illness: _______________________________)☐ Father: ___ years old ☐ Healthy ☐ Ill (Name of illness: _______________________________) ☐Estranged ☐ Deceased (Age: ____)☐ Mother: ___ years old ☐ Healthy ☐ Ill (Name of illness: _______________________________) ☐Estranged ☐ Deceased (Age: ____)☐ Big brother / Big sister / Little brother / Little sister: ____ years old ☐ Healthy☐ Ill (Name of illness: _______________________________) ☐ Deceased (Age: ____)☐ Big brother / Big sister / Little brother / Little sister: ____ years old ☐ Healthy☐ Ill (Name of illness: _______________________________) ☐ Deceased (Age: ____)☐ Big brother / Big sister / Little brother / Little sister: ____ years old ☐ Healthy☐ Ill (Name of illness: _______________________________) ☐ Deceased (Age: ____)

6. Please tell us about your own history of illness.（Including hypertension, diabetes, asthma, and otherillnesses）
Year: ______ Age: _____ Name of illness: __________________ Current medications: ______________
Year: ______ Age: _____ Name of illness: __________________ Current medications: ______________ Year:______ Age: _____ Name of illness: __________________ Current medications: ______________
·

Other medications/supplements:

· Have you ever had surgery? ☐ No ☐ Yes
Year: ______ Age: _____
Year: ______ Age: _____· Have you ever consulted with a counseling psychologist, psychotherapist, or psychiatrist? ☐ No ☐ Yes
Diagnosis ：□Schizophrenia（Age:）□Bipolar disorder（Age:）□Depression(Age:)□Addiction ※Alcohol, Drugs, etc. （Age:)→ Specific addictive substances:（□Other(Age:)（））

9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560 JAPAN; Tel.: 03-3541-5151 Fax.: 03-3544-0649

Copyright © St. Luke's International Hospital All rights reserved
This English translation is true to the original Japanese, but serves as a reference, while the Japaneseversion is the official version that has legal effect and takes precedence in the event of any conflict.

3 /4

7. Please tell us about your lifestyle habits. · Smoking: ☐ I have never smoked.

☐ I used to smoke but no longer do (From age ____ to age ____. About ___ cigarettes per day)☐ I currently smoke (From age ____. About ____ cigarettes per day)· Alcohol: ☐ I do not drink ☐ I drink: (Type: _______________________ Amount: _____ ml per day)stopped drinking after getting pregnant
·☐I

Religious limitations: ☐ No ☐ Yes (Details: ______________________________________________)

8. Please circle the below number that best averages how difficult the past week has been for you. Not at all
0 1 2 3 4 5 6 7 8 9 10 Extremely
To what extent did that difficulty affect your daily life?
Not at all 0 1 2 3 4 5 6 7 8 9 10 Extremely

9. At this hospital, blood transfusion is performed when considered medically indicated in the course of tests,procedures, and surgery. Patients who refuse to undergo blood transfusion cannot be treated here.

☐ I agree to undergo blood transfusion if medically indicated☐ I do not agree to undergo blood transfusion, even though it is medically indicatedThank you for filling out this form. Please submit it to the receptionist.
Integrated Women’s Health, St. Luke’s International Hospital

241029_Ver.4.00_A4 白黒両面

9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560 JAPAN; Tel.: 03-3541-5151 Fax.: 03-3544-0649

Copyright © St. Luke's International Hospital All rights reserved
This English translation is true to the original Japanese, but serves as a reference, while the Japaneseversion is the official version that has legal effect and takes precedence in the event of any conflict.

4 /4