Medical Questionnaire
日本語 English
Step 1 / 8 Basic Info
🌿

Welcome to Our Online Questionnaire

Please complete this questionnaire before your visit
to help us provide the best possible care.

Before You Begin

  • This will take approximately 5-10 minutes
  • All items are optional; however, complete answers help us provide better care
  • Your data is processed only in your browser and is not sent until you submit
  • You can download a PDF or send the responses by email at the end
01

Basic Information

Please provide your name and contact information

Age: －
An interpreter or translation service may be arranged if needed
cm kg
BMI: －
02

Previous Visits to This Clinic

Have you visited our clinic before?

03

Reason for Today's Visit

Please select the most applicable reason.
If you have multiple concerns, select the most pressing one.

04

Symptom Details

Please tell us more about your selected concern

05

Menstrual & Obstetric History

Please complete to the best of your knowledge

Menstrual History

years
★ The cycle is the number of days from the start of one period to the start of the next period
Period Days until the next period Period Start of previous period Start of next period This is the "menstrual cycle" (e.g., 28-day cycle)
If your cycle varies from month to month, please indicate the shortest and longest cycle length.
If your cycle is about the same each month, enter the same number in both fields.
days
days
days

Pregnancy & Delivery History

times
times
times
Medically important. You may leave blank if uncomfortable.
06

Medical History & Medications

Current and past medical conditions

History of thrombosis or breast cancer affects hormone therapy decisions.
07

Allergies, Lifestyle & Family History

For safe care

Allergies

Lifestyle

Family History

08

Consent & Privacy

Please review and confirm

Privacy Policy

Your personal information is handled in accordance with Japan's Personal Information Protection Act and Medical Care Act.

  • Information is used for clinical care, billing, and medical administration
  • If clinically necessary, information may be shared with other healthcare facilities
  • No information is disclosed to third parties without your consent
  • Anonymized data may be used for research and quality improvement
  • Questionnaire data is processed only in your browser until you submit

Clinical Care

  • Please provide accurate information for safe care
  • Our doctor will clarify unclear items during your visit
✓

Thank you for completing the questionnaire

Please use the buttons below

📌 For your visit

  • Print the PDF or show it on your smartphone
  • Please bring your insurance card, patient card, and medication card (Okusuri Techo)
  • New patients: please arrive 15 minutes before your appointment