英語 特殊

Questionnaire for Health Checkup

Medical history
Please place a checkmark in each right box below the name of a disease that you have had or for which you are undergoingtreatment. In addition, please fill your age when you were affected by the disease.

Name:2024 年 4 月からの問診票

If you have no medical history, please place a checkmark in the right blank box.

Use a pencil or mechanical pencil to fill in. Draw a diagonal line in□

1. Smoking (Please indicate if [1] and/or [2] below apply.)[1][2]□□□□□□□□□□□□□□

2. Alcohol

Have been smoking for the past month
Have smoked ≥ 6 months or ≥ 100 cigarettes in lifetime
Neither applies
Only [2] applies□

Both [1] and [2] apply□□

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cigarettes a dayof the applicable column and write a number in the columnyears

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Yes



No□□
□
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days a week

1-3 days a month

Quit drinking(≥ 1 year ago)

Pale

Dizziness/Vertigo

Nausea/vomiting

Anorexia

Abnormal taste

Weight loss

Anxiety/restlessness
DecreasedconcentrationSleep disorder

Excitability

Fatigue/fatigability□□□□□□□□□□□□

Malaise/feelings ofweakness

Mucosalinflammation/abnormality

Reduced/impaired visualacuityConjunctival/corneal
abnormality

Skin
inflammation/abnormality
Skin/eye irritation

Pain in the eye(s)/blurredvision
Photophobia (dazzling)

Lacrimation

Respiratory/upper respiratory
tract irritation
Pharyngeal pain/discomfort

Scratchy throat

Nosebleed/pain in thenose

Chest pain/tightness

Abnormality in the nasal
cavityAbnormal respiratory
symptoms/asthma

Abdominal pain/sense ofabnormality

Abnormal breath sounds

Frequent coughing

Frequent sputum

Palpitation

Change in teeth ordiscoloration
Gingivitis/stomatitis
Enlargement of lymph nodesof neck, etc.

4. Past/present medical history * Enter medical history in the table on the right.
(1) Exposure to the relevant substances inSimple
the event of accident or repair
survey on
working (2) Use of local
Alwaysconditions exhaust ventilation

□□

□

Not
installed□

Sometimes (3)Yes
Use ofprotective
equipment□□□□□□□□□□□□□□□

NoAlways
Not usego/day< 1 day a month3. About recent subjective symptoms (Please choose symptoms that particularly concern you up to 5 items.)
Headache/feelingheavy in the head□

Abnormal reflex of patellar
tendon/Achilles tendon
Parkinsonian symptoms
Pain in the distal part of thelimbs
Numbness/paralysis of thelimbs
Movement disorder such as
finger tremor
Abnormal sensation

Convulsion
Joint pain/
muscle pain
Decreased
grip strengthGait
disturbanceAtaxia□
□
□□
□□□

.

< Rough indication of 1 go of
15% sake (180 mL) >5% beer (about 500 mL)
25% shochu (110 mL)
14% wine (180 mL)
43% whiskey (60 mL)
7% canned chuhai (350 mL)

Cyanosis

Abnormal urination

Defecation abnormality

Abnormal sweating

Jaundice

Bleeding tendency

Nothing in particular[Only for persons whoundergo blood sampling]□□□□[Only for women]

Have felt sick byblood sampling
Have had rash due
to alcohol
disinfection
Have had numbnessin hands after bloodsampling□□

Pregnant or
possibly pregnant
Duringmenstruation

Poor writing□□Don’t know
Sometimes□□

GlassesMask□□

GlovesOther□ProtectiveclothingPast≪Gastric/duodenal disease≫
Chronic gastritis
Gastric ulcer
Duodenal ulcer
Gastric polyps
Gastric submucosal tumor
Gastric diverticulum
Helicobacter pylori positive
Gastric cancer
Other diseases≪Esophageal disease≫
Reflux esophagitis
Esophageal hiatal hernia
Esophageal varices
Esophageal carcinoma
Other diseases≪Colonic disease≫
Colonic polyp
Irritable bowel syndrome
Ulcerative colitis
Crohn's disease
Colon diverticulum
Intestinal obstruction (ileus)
Colon/rectal cancer
Other diseases≪Gallbladder/hepatic/pancreatic disease≫
Gall bladder polyp
Gallstone
Cholecystitis
Hepatitis
Hepatitis B
Hepatitis CFatty liver
Liver cirrhosis
Pancreatitis
Bile duct cancer
Hepatic cancer
Pancreatic carcinoma
Other diseases≪Eye disease≫
Cataracta
Glaucoma
Retinal detachment
Age-related macular degeneration
Retinopathy
Allergic conjunctivitis
Other diseases≪Bronchial/pulmonary disease≫
Bronchial asthma
Bronchiectasis
Pneumonia
Pleuritis
Pneumothorax
Pulmonary cystic disease
Emphysema
Interstitial pneumonia
Pulmonary tuberculosis
Pneumoconiosis / Asbestosis
Lung cancer
Sarcoidosis
Mediastinal tumor
Other diseases≪Cardiovascular disease≫
Hypertension
Angina pectoris
Myocardial infarction
Arrhythmia
Cardiac valvular disease
Cardiomyopathy
Congenital heart disease
Arteriosclerosis obliterans
Venous aneurysm
Aortic aneurysm
Kawasaki’s disease
Other diseases

Undertreatment

Outpatient /No medicine

code

No past history/present illness

Past≪Kidney/urinary tract disease≫
Nephritis
IgA nephropathy
Nephrosis
Pyelonephritis
Hemodialysis
Nephrolithiasis/urolithiasis
Prostatitis
Prostatic hyperplasia
Cystitis
Renal cancer
178 Prostate cancer
147 Bladder cancer
160 Other diseases
162 ≪Skin disease≫
120 Atopic dermatitis
Urticaria
57
Chronic eczema
155 Benign skin tumor
117 Burn
153 Herpes zoster
152 Skin cancer
116 Other diseases
7 ≪Cerebrovascular/cranial nerve disease≫
122 Cerebral infarction
Cerebral hemorrhage
58
Hydrocephalus
59
Parkinson's disease
60
Epilepsy
82
Facial palsy
3Brain tumor
4Meningitis
61
Other diseases
62 ≪Blood disease≫
63Anemia
179 Purpura
138 Aplastic anemia
180 Leukemia
64
Multiple myeloma
Other diseases
27 ≪Endocrine disease ≫28
Hyperthyroidism
181 Hypothyroidism
182 Goiter98
Thyroid cancer
183 Diabetes mellitus
29
Gout/hyperuricemia
Dyslipidemia
46
Other diseases
48 ≪Neuropsychiatric disease≫
43
Autonomic nervous system disorder49
Depression
109 Neurosis
108 Panic disorder47
Adjustment disorder
145 Schizophrenia
1
Other diseases
146 ≪Otic/nasal/pharyngeal/laryngeal disease≫
8Otitis media
221 Sudden hearing loss
166 Congenital deafness
50
Meniere's disease
Allergic rhinitis
36
Sinusitis
102 Tonsillar hypertrophy
103 Vocal cord polyp38
Laryngeal cancer
104 Sleep apnea syndrome
39
Other diseases
105
184
237
185
220
42
53
55
56
54
163
151
164
6121

特殊 36

Undertreatment

Outpatient /No medicine

code

70
238
71
186
7273187
74
128
188
189
190
131

Past≪Bone/muscle/peripheral nerve disease≫
Fracture
LumbagoDisk herniation
Spinal column stenosis
Gonarthrosis
Coxarthrosis
Shoulder periarthritis (frozen shoulder)

Osteoporosis
Neuralgia
Cervical spondylosis
Scoliosis
Rheumatism
Other diseases≪Autoimmune disease≫
100 Systemic lupus erythematosus
191 Scleroderma
192 Dermatomyositis
193 Multiple sclerosis
80
Myasthenia gravis
194 Sjogren's syndrome
195 Other diseases
99 ≪Mammary gland disease≫
Mastitis
41
Mastopathy
40
Galactocele
196 Fibroadenoma
197 Benign mammary neoplasm
24
Breast cancer (right)198 Breast cancer (left)
199 Other diseases
244 ≪Uterine, ovarian and tubal diseases≫
97
Uterine myoma
Endometriosis
14
Adenomyosis uteri
233 Cervical duct polyp200 Ovarian cystoma
11Ovarian cyst
223 Benign ovarian tumor
15
Menopausal symptom
Uterine cervical cancer
201 Uterine body cancer
202 Ovarian cancer
203 Other diseases
245 ≪Traumatic injury≫
17
Cervical sprain
18
Meniscus injury
19
Ligament injury
20Internal injury
Spinal cord injury
25
Limb amputation
21
Other traumatic injury disorders
22 ≪Others≫
234 Other cancers
235 Malignant lymphoma
236 Behcet's disease23
Progressive muscular dystrophy
Post organ transplantation
32
Anal prolapse
33
Temporomandibular joint disease204 Hyperventilation syndrome
34
Other diseases
112
45
205
206
207
208
101

Under
treatment

Outpatient /No medicine

code

79
66
68
209
210
211
212
67
137
213
148
65
69
214
215
216
217
218
219
52
159
75
158
157
92
171
172
239
76
129
176
130
167
156
226
77
174
175
177
133
227
228
229
230
231
232
81
13
222
170
241
242
243
224
225
136

2024.4