Medical Questionnaire - Pediatrics
(小児科問診票)

(1/22)

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 - Pediatrics
(小児科問診票)

(2/22)

2.body parts
(部位(複数回答可))

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Medical Questionnaire - Pediatrics
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(3/22)

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

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Medical Questionnaire - Pediatrics
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(4/22)

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 - Pediatrics
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(5/22)

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

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Medical Questionnaire - Pediatrics
(小児科問診票)

(6/22)

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 - Pediatrics
(小児科問診票)

(7/22)

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 - Pediatrics
(小児科問診票)

(8/22)

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 - Pediatrics
(小児科問診票)

(9/22)

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 - Pediatrics
(小児科問診票)

(10/22)

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 - Pediatrics
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(11/22)

11.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 - Pediatrics
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(12/22)

12.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 - Pediatrics
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(13/22)

13.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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Medical Questionnaire - Pediatrics
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(14/22)

14.Is there any family member who has similar symptoms?
(周り(家族)に同じ様な症状の人がいますか?)

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Medical Questionnaire - Pediatrics
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(15/22)

15.Is there anything unusual about him/her?
(普段と比べて特別変わった様子はありますか?)

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Medical Questionnaire - Pediatrics
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(16/22)

16.Do you have fever reducer at home?
(家に熱さましはありますか?)

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Medical Questionnaire - Pediatrics
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(17/22)

17.Did you use the fever reducer?
(熱さましは使いましたか?)

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Medical Questionnaire - Pediatrics
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(18/22)

18.Has he/she ever had convulsions?
(ひきつけ(けいれん)をおこしたことがありますか?)

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Medical Questionnaire - Pediatrics
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(19/22)

19.What type of medicine is easy to swallow for him/her?
(飲みやすいお薬は何ですか?)

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Medical Questionnaire - Pediatrics
(小児科問診票)

(20/22)

20.Did you travel abroad within the last one month?
(一か月以内に海外旅行をされましたか?)

travel destination (旅行先)
departure date (出発した日)
day (日)
the day when you arrive at Japan (日本に到着した日)
day (日)

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Medical Questionnaire - Pediatrics
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(21/22)

21.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 - Pediatrics
(小児科問診票)

(22/22)

22.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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