Questionnaire*Please fill in this form yourself.

Name2024.4 ~Date of birth

Today's date

Please check any that apply.

Which, if any, of the following have you experienced recently?

 Lack of Headaches or heavy- Diarrhea
 Coughing or Dizziness or unsteadiness Excessive thirstappetite
 Constipationphlegmheadedness Difficulty in sleeping

Heartburn Frequent urination  Swellingpain
Tightness in your  Tingling in your hands or feet  Feeling as if your bladder has not completelychestemptied
Stomach pain
 Intense fatigue or malaise  Shortness or temper Heart palpitations or shortness of breath (during  Irregular Feelings of depression
everyday activities or while walking)heartbeator listlessness

Are you currently being treated for or undergoing follow-up care
for any disease?
(Diseases other than high blood pressure, diabetes, and hyperlipidemia)

 No Yes ( Shoulder stiffness or back

Have you ever had any of the following diseases?
(Medical history)

 High blood pressure  Diabetes)  Tuberculosis
 GoutNo.
Question
1-3 Are you currently taking any of the following drugs ([a] through [c])?
1 a. Medicine to lower your blood pressure
2 b. Medicine to lower your blood sugar or insulin injections
3 c. Medicine to lower cholesterol or neutral lipids
Have you ever been told by a doctor that you’ve had a stroke (cerebral
4hemorrhage, cerebral infarction, etc.), or been treated for stroke?
Have you ever been told by a doctor that you have heart disease (angina,5myocardial infarction, etc.), or been treated for heart disease?
Have you ever been told by a doctor that you’re experiencing chronic renal failure
6or renal insufficiency, or been treated for a related condition (dialysis, etc.)?
7 Have you ever been told by a doctor that you’re anemic?
Are you a regular smoker?
(In this context, you’re a regular smoker if you meet the following two conditions:
8 1. You’ve smoked in the last month.
2. You’ve smoked for at least six months in the past, or you’ve smoked a total ofat least 100 cigarettes over the course of your life.)
9 Have you gained at least 10 kilograms since your weight at age 20?
Have you exercised moderately (enough to produce a light sweat) for 30 minutes
10or more at least twice a week for at least one year?
Do you walk or engage in an equivalent level of physical activity for at least one
11hour a day as part of your daily routine?
12 Do you walk faster than someone of roughly the same age and sex?
13 Which of the following best describes your eating habits?
14 How quickly do you eat compared to others?
15 Do you eat less than two hours before going to bed three or more times a week?
16 How often do you eat snacks or drink sweet beverages between meals?
17 Do you skip breakfast three or more times a week?
How often do you drink alcoholic beverages (Japanese sake or shochu, beer,wine, etc.)?
18(In this context “I quit drinking” means you used to drink at least once a month but
have not had alcoholic beverages for at least a year.)
How much do you drink a day?
In this context, one drink means 180 mL of a beverage that contains 15% alcohol,or about:
19500 mL of beer (5% alcohol), 110 mL of shochu (25% alcohol), 180 mL of wine(14% alcohol), 60 mL of whiskey (43% alcohol), 350 mL or 500 mL of sour-type
mixed drinks sold in cans (7% or 5% alcohol, respectively)
20 Do you feel refreshed after a night’s sleep?

21

Are you interested in exercising more or otherwise enjoying a healthier lifestyle?
When did you start making changes, or when do you plan to start?

22

Have you ever received specific health guidance to help you enjoy a healthierlifestyle?

 Hyperlipidemia  Liver disease Other ()Answer

① Yes
① Yes
① Yes

② No
② No
② No① Yes

② No

① Yes

② No

① Yes

② No

① Yes
② No
① Yes (I meet both conditions.)② I used to smoke, but I haven’t smoked inthe last month. (I meet only the secondcondition.)③ No (I meet neither condition.)
① Yes
② No
① Yes

② No

① Yes

② No

① Yes
② No
① I can chew and eat anything.
② Some foods are difficult to chew, and I haveconcerns about my teeth, gums, bite, etc.
③ I can hardly chew.
① Faster② About the same
③ Slower① Yes② No① Every day② Occasionally③ Almost never
① Yes
② No
① Every day② Five or six days a week
③ Three or four days a week
④ Once or twice a week
⑤ One to three days a month⑥ Less than once a month⑦ I quit drinking.
⑧ I don’t drink. (I can’t drink.)① Less than one② At least one but less than two③ At least two but less than three④ At least three but less than five
⑤ Five or more
① Yes
② No
① I’m not interested in making any changes.
② I'm interested in making changes and will
start in the next six months or so.
③ I will start making changes soon (within
about a month).
I’m interested in making changes and am
taking a gradual approach.
④ I started making changes within the last
six months.
⑤ I started making changes at least sixmonths ago.
① Yes

② No

Additionalinformation