Medical Questionnaire - Obstetrics and Gynecology
(産婦人科問診票)

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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 - Obstetrics and Gynecology
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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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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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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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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 - Obstetrics and Gynecology
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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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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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(産婦人科問診票)

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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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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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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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(産婦人科問診票)

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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 been given anesthetics including dental anesthesia?
(麻酔をしたことがありますか?(歯科での麻酔を含む))

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15.Have you ever been pregnant before?
(今まで妊娠したことがありますか?)

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(産婦人科問診票)

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16.Questions for women who have been pregnant before.
(妊娠したことある人はお答えください。)

Normal delivery (正常分娩)
time(s) (回)
Caesarean section (帝王切開)
time(s) (回)
Natural abortion (流産)
time(s) (回)
Induced abortion (中絶)
time(s) (回)

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17.Menstrual history
(あなたの月経についてお答えください。)

First period (初潮)
years old (歳)
Menopause (閉経)
years old (歳)

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(産婦人科問診票)

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18.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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19.Compare with your usual menstruation, the flow of the last few ones are
(この最近は普段の量に比べて)

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20.What is your menstrual periodic cycle?
(月経周期は)

days periodic form (日型)

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(産婦人科問診票)

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21.Do you have any pain during your period?
(生理痛はありますか?)

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(産婦人科問診票)

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22.Are you married?
(現在、結婚はされていますか?)

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(産婦人科問診票)

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23.Have you ever had sexual relations?
(性交渉の経験はありますか?)

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(産婦人科問診票)

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24.History of pregnancy
(妊娠歴)

First child (第一子)
Delivery date (出産年月)
year (年)
Length of pregnancy (妊娠期間)
weeks (週)
Sex (性別)
Weight (体重)
g
Abnormality in childbirth (分娩時に異常はありましたか?)
Please explain that/those. (それについて説明してください。)
Place of childbirth (出産場所)
Second child (第二子)
Delivery date (出産年月)
year (年)
Length of pregnancy (妊娠期間)
weeks (週)
Sex (性別)
Weight (体重)
g
Abnormality in childbirth (分娩時に異常はありましたか?)
Please explain that/those. (それについて説明してください。)
Place of childbirth (出産場所)
Third child (第三子)
Delivery date (出産年月)
year (年)
Length of pregnancy (妊娠期間)
weeks (週)
Sex (性別)
Weight (体重)
g
Abnormality in childbirth (分娩時に異常はありましたか?)
Please explain that/those. (それについて説明してください。)
Place of childbirth (出産場所)

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Medical Questionnaire - Obstetrics and Gynecology
(産婦人科問診票)

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25.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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