Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(1/19)

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))

Next (次へ)

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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(2/19)

2.body parts
(部位(複数回答可))

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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(3/19)

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

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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(4/19)

4.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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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(5/19)

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

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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(6/19)

6.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 - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(7/19)

7.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 - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(8/19)

8.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 - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(9/19)

9.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 - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(10/19)

10.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 - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(11/19)

11.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 - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(12/19)

12.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 - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(13/19)

13.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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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(14/19)

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

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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(15/19)

15.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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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(16/19)

16.Have you ever got vaccinated within the last three months? Or do you have a plan to get a vaccine?
(最近3ヶ月間以内に予防接種を受けましたか?(今後予定がありますか))

1. Details (1. 詳細)
immunization against (予防接種名)
day (日)
2. Details (2. 詳細)
immunization against (予防接種名)
day (日)
3. Details (3. 詳細)
immunization against (予防接種名)
day (日)
4. Details (4. 詳細)
immunization against (予防接種名)
day (日)
5. Details (5. 詳細)
immunization against (予防接種名)
day (日)

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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(17/19)

17.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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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(18/19)

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

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Medical Questionnaire - ENT (ear, nose, and throat)
(耳鼻咽喉科問診票)

(19/19)

19.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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