Medical Questionnaire
There are a total of four pages. Please fill out all documents.
Name:
Date of birth://Age:

Sex: □ M □ FAddress:
Phone:--Nationality (国籍):Hight:

Occupation (職業)：
Weight㎝・feet( 1 feet = 30.48 ㎝ )kg・pound( 1 pound = 0.453 kg )♦Do you drink alcohol? □ No / □ Yes → □ everyday

ml / □ sometimeml□ Sake / □ beer / □ wine / □ whisky / □Other♦Do you smoke cigarettes?

□ No / □ Yes → How many do you smoke a day?

❶Do you have any problems related to sleep? (夜の睡眠でお困りの症状はありますか？)□ The difficulty falling asleep (寝つきが悪い)□ Frequent awakening during sleep (しばしば目が覚める)□ Waking up early in the morning (朝早く目が覚める)□ Having shallow sleep (眠りが浅い)□Frequent urination at night (夜間頻尿)□Morning dry mouth (起床時の口渇)❷About your sleep duration over the past month (最近 1 か月間の睡眠時間)
You go to bed at () o'clock and wake up at () o'clock on weekdays.

You go to bed at () o'clock and wake up at () o'clock on weekends.

❸Do you experience the following symptoms during sleep?(以下の症状がありますか？)□Snore (いびき) / □Sleep apnea (睡眠中の無呼吸) / □sleep paralysis (金縛り)□Restless legs when trying to fall asleep, causing an irresistible urge to move
(寝つくときに足がムズムズして動かさずにはいられない)□Sometimes getting up from bed and walking around during sleep, but notremembering upon waking up(睡眠中に起きて歩き回るが、起きると忘れてしまう)□Hallucinations while falling asleep or having dreams shortly after falling asleep(寝入り際に変なものが見えたり、眠ってすぐに夢を見る)❹ Do you experience excessive daytime sleepiness? (日中の強い眠気)□ No / □ Yes → Please also answer the following questions.
♦Do you experience unintentional dozing off? (居眠りの有無)□ No / □ Yes → How many times a day do you doze off?
(1 日に何回ぐらい居眠りしますか？)/ day

→ For how long do you doze off each time?(1 回の居眠り時間)□Less than 30 minutes / □Around 1 hour / □Several hours / □Varies♦What time of day do you experience strong sleepiness? (強い眠気の時間帯)□Morning / □Noon to evening / □Evening onwards / □It doesn't matter♦What is your level of sleepiness after dozing off? ( 居 眠 り し た 後 の 気 分 )□Refreshed / □Not refreshed / □Neither♦ Have you ever driven while dozing off?(居眠り運転の有無) □ No / □ Yes♦Do you have a history of car accidents?(交通事故歴)□ No / □ Yes❺Do you suddenly experience muscle weakness when you laugh or get angry?
(怒りや笑いによる脱力)□ No / □ Yes →Onset age/ Areas of the body(年齢・部位)❻Do you have any troubling physical symptoms? (困っている身体症状)□Fatigue / □Headache / □Dizziness / □Loss of appetite / □Overeating□Constipation or diarrhea / □Frequent urination / □Other(倦怠感・頭痛・めまい・食欲不振・過食・便秘や下痢・頻尿・その他)❼Have you previously had any of the diseases listed below?(既往歴)□Myocardial infarction(心筋梗塞)□Angina pectoris(狭心症)□Hypertension(高血圧)□Arrhythmia(不整脈)□Other cardiac disorders(その他心疾患)□Cerebral infarction(脳梗塞)□Cerebral hemorrhage(脳出血)□Other cerebrovascular disorders(その他脳血管障害)□Respiratory disease (□Emphysema・□Tuberculosis・□Asthma)(呼吸器疾患 肺気腫・結核・喘息）□Ophthalmic disorders (□Glaucoma・Other:)(眼科疾患 緑内障・その他）□Otorhinolaryngological disorders (□Rhinitis・□Tonsillar Hypertrophy・ □Sinusitis・□Other:(耳鼻科疾患 鼻炎・扁桃肥大・副鼻腔炎・その他）□Hyperlipidemia(高脂血症)□Fatty liver(脂肪肝)□Diabetes(糖尿病)□Other:)❽ Do you currently have any medical conditions being treated or are you taking anymedications? (現在、治療中の病気や服用している薬はありますか？)□ No / □ Yes →Please show us the medications if you have them with you.
(もし薬を持っていれば見せて下さい)❾Do you have any allergies?(アレルギーはありますか?)□ No / □ Yes → □Medication (薬)□Food (食物)□Other❿Is there a possibility that you are pregnant? (妊娠していますか、可能性はありますか?)□ No / □ Yes→ months pregnant (妊娠カ月)□I do not know (わからない)

The Epworth Sleepiness Scale (ESS: 眠気の程度)
How likely are you to doze off or fall asleep in the following situations? You should rate yourchances of dozing off, not just feeling tired. Even if you have not done some of these things
recently try to determine how they would have affected you. For each situation, decide
whether or not you would have:♦No chance of dozing=0 (決してうたた寝しない)♦Slight chance of dozing=1 (まれにうたた寝する)♦Moderate chance of dozing=2 (ときどきうたた寝する)♦High chance of dozing=3 (しょっちゅううたた寝する)

Please Write down the number corresponding to your choice in the right hand column.
Situation

Chance of Dozing

Sitting and reading
Watching TV
Sitting inactive in a public place (e.g., a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Total Score = ________________

Sleep diary
FillingExample

NameMorning

Afternoon

Feeling

Activities
Physical condition

2/2
2/3
Business trip

2/4
2/5
2/6

Headache2/7

Travel2/8↓ ↓ ↓ Please fill in from here ↓ ↓ ↓///////////////////////

Instructions for filling in♢ Sleep quality

Goodsleep

Drows
iness

Unableto sleepin bedNot inbed♢ Activities/ Physical condition:business trips, travel, headaches, menstruation, fatigue, etc.

Record of medications
please mark the time of administration.
<Example> 〇 Zolpidem 1 tablet▲ pain reliever 1 tablet