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Medical Questionnaire Form
Shinagawa Diagnostic & Preventive Care
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Medical Questionnaire Form
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Medical Questionnaire
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Date of Examination:
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I. Personal Information
8. for day
Name
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First
Middle
Last
Suffix:
Sex:
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Male
Female
Date of Birth:
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Email Address:
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II. Medical History
Have you had any illness or been hospitalized since your last visit?
III. Medication History
Please list down below all present medications and supplements you are taking:
Next
IV. Subjective Symptoms
Are there any medical symptoms you are currently experiencing as of the moment?
V. Specific Health Assessment
1. Do you perform light sweating exercises for at least 30 minutes at a time for at least 2 days a week for at least 1 year?
Yes
No
2. Do you walk, or have equivalent physical activity for 1 hour or more daily?
Yes
No
3. How often do you drink alcohol (sake, soju, beer, liquor, etc.)?
4. How much alcohol is consumed per day on drinking day?
VI. OB/GYN History (For female patients only)
1. Menstrual history
A.) At what age did your first menstrual period start?
B.) Have you reached menopause? If yes, at what age?
C.) Date of your last period:
2. Pregnancy history
A.) Are you pregnant or possibly pregnant?
Yes
No
Not Sure
B.) Have you ever been pregnant?
Yes
No
C.) Have you ever had a miscarriage or abortion?
Yes
No
D.) Do you have any children? If yes, how many living?
3. Are you breastfeeding?
Yes
No
4. Did you undergo breast augmentation surgery and breast reconstruction?
Yes
No
5. Last schedule of your Mammography?
6. Last schedule of your Breast Ultrasound
7. Last schedule of your Visual Palpation?
8. Last schedule of your Pap smear?
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