For Those Undergoing Palliative Care Outpatient Consultation
Please provide the following information which we need to make decisions on your palliative care treatment and future treatment
policy. Your information will be handled confidentially. It will not be used for any other purposes than the provision of medicalcare, and your privacy will be protected.

Name：

Date of birth:

YYYY / MM / DD

Person accompanying the patient：

Relation：①telephone number：Contact
information ②telephone number：
1.

Age（ home ・ mobile ） name：relation：（ home ・ mobile ） name：relation：

What made you seek care at the Palliative Care Department?
□Choice of patient□Requested by family□Recommended by physician□Recommended by friend/colleague□Other（2.

）

Would you like to take a tour of the hospital ward today? ※Available 10AM-12PM and 1:30PM–3:30PM□Yes □No

3.

At present, which of the following symptoms are you suffering from? (Check all that apply)□Pain□Trouble breathing□Trouble Eating□Swelling□Coughing□Bloating□Trouble Sleeping□Trouble urinating□Nausea/vomiting□Feeling depressed□Trouble thinking clearly□Fatigue□Constipation□Sleepiness□Diarrhea□Worrying□No severe symptoms□Other（4.

）

Is there anything in addition to your health that you are concerned about?
□Family（）□Work（）□Finances （）□Other）（5.

□N/A
How has your present condition been explained to you?

6.

How has your attending doctor explained the treatment that you will receive from now on?

SLIH-2018.7.9-Ver.2.0
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.

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7.

How has palliative care been explained to you?

8.

What are your expectations of palliative care?

9.

If you have any questions or concerns about palliative care, please note them here.

10. Please indicate the medical treatments you are currently receiving (Please provide as muchdetail as possible)□Anticancer treatment（）□Alternative treatments （）□Gastrostomy □Urethral balloon catheter□Oxygen□Nephrostomy □CV Port□Stoma □Blood glucose monitoring □Insulin injections□Bedsore treatment□Pacemaker□Blood transfusions□High caloric IV□Narcotics for medical use□Others ()11. Please provide information on any allergies□Yes, I have allergies（）□No allergies
12. Please provide information on your lifestyle habits.
Smoking history： □No□ Yes (From age

Present drinking habit: □No □Yes (beer:

toyears, approx.

bottles, rice wine:

cigarettes a day)go, wine:

glasses. whisky:

tots/day)Are you covered by Care/Nursing Insurance?
□Have not applied□Currently applying□Have applied （□Required Care: 1 / 2 / 3 / 4 / 5 □Required Support: 1 / 2 □Not applicable）□Currently under renewal□Do not wish to use care/nursing insurance services□Care manager （Company：）

Person in charge：

13. Specify the services/items you currently utilize from the following:□Home visiting nursing（____times/week） □Home visiting care（____times/week）□Home visiting doctor（____times/week or ____times/month）□Bathing assistance（____times/week）□Day-care service（____times/week）□Short-stay/Temporary care□Home-delivery meals/food104-8560 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.

2/3□Assistive equipment （□Wheelchair □Care/Nursing bed □Shower/bath seat □Portable toilet□Home renovations （□Handrails □Ramps □Other （）14. Do you have certification for physical disability?
□ NO □YES→Disability category（）（Level）

15. Please specify any other support services you utilize:（）

16. Please indicate your occupation. (You may specify if you are retired or on leave).
（）

17. At St. Luke's International Hospital, patients are treated with blood transfusion when deemed medicallynecessary. Do you agree to undergo blood transfusion? □ Yes□ No（Reason：□ Yes （18. Do you have any faith or religion?

）
）

□ No

19. Family Information
Age

Living/Deceased

Place of Residence※Please write the name of city/ward/town

Relative

Sex

Father－Living/Deceased

Living together / separately (location:)

Mother－Living/Deceased

Living together / separately (location:)

SpouseM/F

Living/Deceased

Living together / separately (location:)

M/F

Living/Deceased

Living together / separately (location:)

M/F

Living/Deceased

Living together / separately (location:)

M/F

Living/Deceased

Living together / separately (location:)

M/F

Living/Deceased

Living together / separately (location:)

M/F

Living/Deceased

Living together / separately (location:)

M/F

Living/Deceased

Living together / separately (location:)

M/F

Living/Deceased

Living together / separately (location:)

M/F

Living/Deceased

Living together / separately (location:)

M/F

Living/Deceased

Living together / separately (location:)Children

Siblings

20. Is there a person whom you wish to make decisions on your behalf in case you are in a conditionin which you cannot make decisions about your treatment yourself?
□Yes (Name:Relation:）□No□UnsureThank you for your cooperation
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.

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