For Patients Visiting the Department of Psychosomatic Medicine
Name：

Age：

Sex： Male ・ Female
Occupation：y.o.

Marital status: Married / Single/ Divorced/ Bereavement
Type of work：

Phone Number (Please provide a phone number where we can reach you if necessary)Tel.

1. Specify the issues you currently face. *Place them in order, from the biggest issue first.
①②③④⑤
Others

2. Provide background information on the symptoms of the above problems.
(Give details such as when the symptoms started and under what circumstances, any changes in the symptoms, historyand results of treatment.)◆ How did you hear about our Department of Psychosomatic Internal Medicine?

3. Have you had any previous serious illness surgery or have you been hospitalized before?
AgeIllness

Hospital where you
have been treatedDetails of treatment

Results of treatment

104-8560 東京都中央区明石町 9 番 1 号 Tel.03-3541-5151 Fax. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.
English-language sentences shall conform to their Japanese-language counterparts.
Any legal responsibility involved shall be governed and construed based on Japanese-language sentences.

Yes ・ No

4. Do you have any allergies?
Medication
Food

5. List any medications you are currently taking.

6. Complete the following about the structure and medical history of your family.
*Include yourself and any brothers or sisters.
Grandfather
GrandmotherGrandfather

FatherMotherGrandmother

Relationship with anyone who has the following
illnesses
High blood pressure （）Stroke（）Heart disease（）
Cancer（）Diabetes（）
Asthma（）Mental illness（）* Who was primarily responsible for your upbringing? (Father / Mother / Other)

7. Last school or employment(years of continuous service)
8. Daily routineTime when you get up:
Time when you go to bed:
Time when you start work:
Time when you finish work:
Average working hours:
Meals:
times /dayAppetite:
Smoking habit:
cigarettes / day, never
Daily alcohol intake: Japanese sake, beer, wine, otherml / day, at times, neverSport or regular exercise:
Hobbies:good,poor

104-8560 東京都中央区明石町 9 番 1 号 Tel.03-3541-5151 Fax. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.
English-language sentences shall conform to their Japanese-language counterparts.
Any legal responsibility involved shall be governed and construed based on Japanese-language sentences.

9. During the past 4weeks, how much have you been bothered by any of the following problems ?
Not bothered
at allBothereda little

Bothereda lot1)

Stomach pain

□

□□2)

Back pain□□□3)

Pain in your arms, legs, or joints (knees, hips, etc.)□□□4)

Menstrual cramps or other problems with your periods(women only)□□□5)

Headaches□□□6)

Chest pain□□□7)Dizziness□□□8)

Fainting spells□□□9)Feeling your heart pound or race□□□10) Shortness of breath Palpitations or quick pulse□□□

11) Pain or problems during sexual intercourse
12) Constipation, loose bowels, or diarrhea

□

□□□□□

13) Nausea, gas, or indigestion
14) Feeling tired or having low energy

□□□

□□□

15) Trouble sleeping□□□≪PHQ-15 (Patient Health Questionnaire-15) by Kroenke K, Spitzer RL et al 2002≫
10. What is your impression of your current situation? Please include any ideas you might have about possible factors thatcaused or triggered your symptoms.
(including stress arising from your living environment or personal relationships at home, school or work).

11. How would you like things to change or to change things in the future?

12. At St. Luke's International Hospital, patients are treated with blood transfusion when deemed medically necessary.
Do you agree to undergo blood transfusion in the event it becomes medically necessary?
Yes ・ No

104-8560 東京都中央区明石町 9 番 1 号 Tel.03-3541-5151 Fax. 03-3544-0649
Copyright © St. Luke's International Hospital All rights reserved.
English-language sentences shall conform to their Japanese-language counterparts.
Any legal responsibility involved shall be governed and construed based on Japanese-language sentences.