Medical questionnaire

Can you speak or understand Japanese language?(required)
SpeakUnderstandDifficult to speakDifficult to understandOthers

Can someone(friends, aquaintance) who understands Japanese come with you?(required)
YesNo

Do you need an interpreter?(required)
YesNo

At which clinic did you make your appointment? (required)
IgarashiDental(Shimooka/028-673-6661)IgarashiDentalEast(Hiraamatsu/028-611-3085)
Name (required)

MailAddress. (required)

Date of birth (required)

●Postal code(required)

◆Address.(required)

TEL(required)

Occupation(required)
Company employeeSelf employedCivil servantParttimeStudentHouse wife/husbandOthers

How did you hear about us?(required)
AcquaintanceReferred by other clinicHomepagePassing byOthers
*For referrals from acquaintances or medical institutions, please provide the information below.

1.Reason for visiting clinic（Please check the box）
ToothacheTooth mobilityBlack cavityTooth fillings fell outsensitivity(Cold・hot)Denture treatmentwhiteningGum problemTeeth cleaningOrthodontic TreatmentImplant TreatmentOthers

*Other reasons for visiting the clinic.

2.Is there any pain?（Please check the box）
ToothGumJawOthers
*Other areas of pain.

3.Did you had any dental treatment before?
Last dental treatment date

4.Have you ever had anesthetic injection?How did you feel at that time?
Felt nothingUncomfortable

5.Have you ever had any of the following illness?For those for whom it applies, please fill in the information.
NoYes
HypertensionHeart disease（Ischemia/arrhythmia/Hait failure/Pacemaker/Others)Cerebrovascular Disease DiabetesEpilepsyThyroidAsthmaKidneystomach・intestinePancreasHepatitis （TB/C/Other））Blood diseaseGynecological diseaseAllergy

・Allergy
・Others

6.Are you currently receiving treatment at any other medical institution?If you are not currently attending outpatient appointments.
Name of Medical institution1

Disease name1

Medication1

Name of Medical institution2

Disease name2

Medication2

Others

7.Have you ever experienced side effect from the over the counter(OTC) Drug or medicine prescribed by dentists or doctors?For those for whom it applies, please fill in the information.
Medication name.

Symptoms.

8.Is there anything that applies to your daily life?
*difficult to eat hard food compared to six month beforeYesNo
*Chocking while having tea or soupYesNo
*Concerned about dry mouthYesNo

9.For female, Are you pregnant currently?
YesNoNot sureBreastfeeding

10.For those who are　40　years or above, Did you have specific health checkup or elderly health checkup in the past year?
YesNo

11.For those who use My number Health insurance card, do you agree to the acquisition of your medical information (Information on medical notebook)?
AgreeDisagree((Even if you disagree, there will be no any disadvantage in your treatment)

12.Regarding treatment
I want the treatment covered by health insurance.If the insurance doesn’t cover, I don’t mind paying certain amount.I want to decide after consulting with dentist.

13.Smoking history
YesNo

14.If you have any other questions or requests, please write below.

I consent to the transmission of my personal information to the hospital.

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