Synopsis of patient history

We'll make the referral in Japanese for you so that you can take it to the clinic with you. No charge for translation.

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We'll reply to you within 48hours.

Synopsis of

Name;

E-mail;

Date;

Age;

Sex; Female Male

Height; cm

Weight;kg

1. Vital signs; (You can write as much as you know.)

Blood pressure;

Pulse rate;

Respiration rate;

2. Under care of a physician;

Condition;

3. Hospitalized within the last five years;

Reason;

4. Has or had the following conditions;

Heart murmur, Heart attack, Angina pectoris, Hypertension, Diabetes mellitus,

Hepatitis, Bleeding disorder, Asthma, Allergy (medication, food),

other,

Please write the detail and your concern in the Medical history or Remarks.

5. Current medications;

Anticoagulants Insulin Antibiotics Aspirin Nitroglycerin

High blood pressure medication Corticosteroids Oral contraceptives

Other

Please write the name of medication, dosage and your concern in the Medical history or Remarks.

6. Smokes or uses tobacco products;

Yes No

7. Is pregnant;

Yes No

Chief complaint;

Dental history;

Medical history;

Social history;

Remarks; you can write your concern, your expectation about the treatment and whatever in your mind.