Medical Questionnaire - Internal Medicine
(内科問診票)

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1.What brings you here today? (multiple answers allowed)
(今日はどうされましたか?(複数回答可))

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Medical Questionnaire - Internal Medicine
(内科問診票)

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2.When did the symptom(s) start?
(それはいつからですか?)

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Medical Questionnaire - Internal Medicine
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3.Was there anything to be caused for the symptom(s)?
(症状の原因となることはありましたか?)

What is the cause of that/those? (原因は何ですか?)

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4.The above symptom(s) recently
(上記の症状は最近)

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Medical Questionnaire - Internal Medicine
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5.Are there any diseases you have had or you are in treatment?
(今までにかかった病気や現在治療中の病気はありますか?(複数回答可))

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Medical Questionnaire - Internal Medicine
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6.Are you currently taking internal medicine?
(現在服用中の内服薬はありますか?)

What is that? / What are those? (それは何ですか?)

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Medical Questionnaire - Internal Medicine
(内科問診票)

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7.Have you ever had allergic reactions to food, like itchiness or rash?
(食べ物でアレルギー(かゆみ・発疹など)を起こしたことがありますか?)

What is the cause of that/those? (原因は何ですか?)

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Medical Questionnaire - Internal Medicine
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8.Have you ever had allergic reactions to medicines, like itchiness or rash?
(薬でアレルギー(かゆみ・発疹など)を起こしたことがありますか?)

What is the cause of that/those? (原因は何ですか?)

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Medical Questionnaire - Internal Medicine
(内科問診票)

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9.Is there any hospital you are in treatment now?
(現在、受診されている病院はありますか?)

name of the hospital (病院名)
Departments (診療科名)

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Medical Questionnaire - Internal Medicine
(内科問診票)

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10.Do you drink?
(お酒は飲みますか?(複数回答可))

What is that? / What are those? (それは何ですか?)
glasses (杯) /

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Medical Questionnaire - Internal Medicine
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11.Do you smoke?
(タバコは吸いますか?)

the year when you started smoking (吸い始めた年)
years old (歳)
cigarettes/day (本/日)
the year when you started giving up smoking (禁煙を始めた年)
years old (歳)

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Medical Questionnaire - Internal Medicine
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12.Have you ever had any operations?
(手術をしたことがありますか?)

name of the disease (病名)
years old (歳)

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13.Have you ever had a blood transfusion?
(輸血をしたことがありますか?)

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14.Have you ever had your tooth pulled out?
(歯を抜いたことがありますか?)

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15.Questions for women: Is there any chance that you may be pregnant?
(女性の方へ:現在、妊娠の可能性はありますか?)

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16.Are you currently breastfeeding?
(現在授乳中ですか?)

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17.When was your last period?
(一番最近の月経はいつからですか?)

Date the last period started (月経が始まった日)
day (日)
Date the last period ended (月経が終わった日)
day (日)

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Medical Questionnaire - Internal Medicine
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18.If you have any comments or requests, please write in.
(その他、何かご希望がございましたらご記入ください。)

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