英語 一般

Questionnaire for Health Checkup
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.)

2. Alcohol[1][2]□□Have been smoking for the past month
Have smoked ≥ 6 months or ≥ 100 cigarettes in lifetime□

Neither applies□□



Only [2] applies

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

Both [1] and [2] apply□□years

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

Yes



No

□□□□□□□

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

.

Past

days a week□

1-3 days a month

Quit drinking(≥ 1 year ago)

□go/day< 1 day a month< 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)

3. About recent subjective symptoms (Please choose symptoms that particularly concern you up to 5 items.)

□□
□
□
□□□
□
□□
□
□
□
□
□
□
□
□

Eye fatigue
Tinnitus
Dizziness/Vertigo
Frequent coughing
Frequent sputum
Palpitations (heart pounding)Respiratory distress
Irregular pulse
Sometimes have squeezing
chest pain

Loss of appetite
Frequent stomachache
Frequent nausea and vomiting
Frequent heartburn andburping
Prone to diarrhea
Tendency to be constipatedFrequent abdominal pain
Frequent urination (> 10 timesa day)Feeling of residual urine□□□□□□□□□

Shoulder (neck)stiffness/shoulder(neck) pain
Low back pain
Joint pain
Headache/heavinessof the head

Sudden weight loss
Have allergy
Nothing in particular[Only for persons who[Only for women]
undergo blood sampling]
Have felt sick byPregnant orblood sampling
possibly pregnant
Have had rash due toDuring
alcohol disinfection
menstruation
Have had numbnessin hands after blood
Breastfeedingsampling□□□

Swelling in hands/feet
Unable to sleep/difficultyfalling asleep
Waking up early in themorning
Frequent dryness in themouth and throat□□□

Often irritated or restless

4. Recent living conditions(1) Chewing condition when eating food□□□Able to chew anything
Have difficulty in chewing due toproblematic teeth, gums, or bite
Hardly able to chew(2) Comparing with others, the speed of eatingis:□Faster□□

At an average
speedSlower(3) Take snacks and sweet beverages other than
3 meals of breakfast, lunch, and dinner□

Everyday□□Occasionally(5) Improvement of lifestyle such as exercising andeating(4) Lifestyle habits

Hardly□□□□□□□□□□□□

Skip breakfast at least 3 times a week
Have dinner within 2 hours of going tosleep, 3 times or more each week
Increase by ≥ 10 kg compared with the weight at theage of 20
Do light exercise for ≥ 30 minutes per time for ≥ 2days a week for ≥ 1 year
Do walking or equivalent physical activity for ≥ 1hour a day in daily life
Walk faster than those of the same sex at almost thesame age

Have no intention of improving
Intend to improve (within 6 months)
Intend to improve in the near future (within 1month) and have gradually started
Have already worked on improvement (< 6months)
Have already worked on improvement (≥ 6months)(6) Have you received specific health guidance
before?

□Have enough rest by sleeping

□

Yes

No

5. Work history (Those who are currently “on a leave of absence” or "unemployed" do not have to answer the following questions.)(1) Past work history□□□□□(3) Average working hours per day (lastmonth)(2) Current work system□□□Handling of heavy materials
Handling of dust
Severe vibration□□□□

Regular day shift
Regular night shift
Shift work

Handling of hazardous
substances(4) Average number of working days perweek (last month)□□□□< 6 hours
6 to < 8 hours
8 to < 10 hours≥ 10 hours< 3 days
3 to < 5 days
5 days≥ 6 days

Handling of radiation

6. Medications□□

Drug to lower bloodpressure□

Drug to lower
cholesterol orneutral fat

Drug to lower blood
glucose or insulin
injection

7. Past/present medical history * Enter medical history in the table on the right.
< The following questions are for women who undergo breast cancer screening/Pap smear test. >Menstrual
history□□□Pregnancy
history

Number of
pregnancies

Subjectivesymptoms

Lump in the breast
Severe menstrual pain
Regular□

Irregular□time(s)□□□□□Pain in thebreast
Discharge

Lactation or other secretion
Abnormal vaginal bleeding□ □ □ □□Last
Menorrhagia menstrualMM
periodNatural
Cesareantime(s)deliverysection□DD-time(s)MMDD

Menopause□Aroundyears
old≪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 C
Fatty liver
Liver cirrhosis
PancreatitisBile 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
CardiomyopathyCongenital 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≫63
Anemia179 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 Neurosis108 Panic disorder47
Adjustment disorder
145 Schizophrenia
1
Other diseases
146 ≪Otic/nasal/pharyngeal/laryngeal disease≫8
Otitis 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

一般 18

Under
treatment

Outpatient /No medicine

code

70
238
71
186
72
73
187
74
128
188
189
190
131

Past≪Bone/muscle/peripheral nerve disease≫
FractureLumbago
Disk 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
32Anal 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