Check all corresponding answers. Name INTERNAL MEDICINE Male English year month day Female Date of birth Address year month day Phone Do you have heal

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2 INTERNAL MEDICINE year month day Date of birth Address year month day Phone Do you have health insurance? Nationality YesNo Language What are your symptoms? fever( ) sore throat cough headache chest pain rash heart palpitation shortness of breath swelling dizziness tightness in chest abdominal pain stomachache high blood pressure numbness excessive thirst weight loss abdomen feels swollen loss appetite vomiting nausea diarrhea bloody stool weak excessive fatigue others How long have you had these problems? Since year month day Do you have any food or medication allergies? YesmedicationfoodothersNo Are you currently taking medication? YesIf you have any with you now, please show them to me.no Are you pregnant or is there a possibility of pregnancy? YesmonthsNo Are you currently breastfeeding? YesNo What illnesses have you had in the past? stomach and intestinal disorder liver disease heart disease kidney disease tuberculosis diabetes asthma high blood pressure AIDS/HIV thyroid problems syphilis others Are you currently under medical treatment? Have you ever had any operations? Have you ever had a blood transfusion? YesNo YesNo YesNo Can you arrange an interpreter by yourself for your next visit? YesNo

3 Date of birth Address SURGERY year month day Phone year month day Do you have health insurance? Nationality YesNo Language What are your symptoms? fever( ) stomachache injury burn lump numbness sprain weight loss itching gallstone swelling hemorrhoids bloody stools throat(thyroid gland) hernia others neck lungs breast stomach Umbilicus(Navel,BellyButton) Intestine How long have you had these problems? Since year month day Circle on the picture. Do you have any food or medication allergies? YesmedicationfoodothersNo Are you currently taking medication? YesIf you have any with you now, please show them to me.no Are you pregnant or is there a possibility of pregnancy? YesmonthsNo Are you currently breastfeeding? YesNo What illnesses have you had in the past? stomach and intestinal disorder liver disease heart disease kidney disease tuberculosis diabetes asthma high blood pressure AIDS/HIV thyroid problems syphilis others Are you currently under medical treatment? Have you ever had any operations? Have you ever had a blood transfusion? Have you ever had any trouble with anesthesia? YesNo YesNo YesNo YesNo If you have a letter of referral to this hospital, please answer the following questions. Do you have a previous X-ray with you? Do you have a previous endoscope with you? YesNo YesNo

4 Can you arrange an interpreter by yourself for your next visit? YesNo

5 Date of birth Address ORTHOPEDICS year month day Phone year month day Do you have health insurance? Nationality YesNo Language What are your symptoms? fever( ) pain injury lump itching sprain others burn swelling numbness weight loss How long have you had these problems? Since year month day Do you have any food or medication allergies? YesmedicationfoodothersNo Circle on the picture. Are you currently taking medication? YesIf you have any with you now, please show them to me.no Are you pregnant or is there a possibility of pregnancy? YesmonthsNo Are you currently breastfeeding? YesNo What illnesses have you had in the past? stomach and intestinal disorder liver disease heart disease kidney disease tuberculosis diabetes asthma high blood pressure AIDS/HIV thyroid problems syphilis others Are you currently under medical treatment? Have you ever had any operations? Have you ever had a blood transfusion? Have you ever had any trouble with anesthesia? YesNo YesNo YesNo YesNo Can you arrange an interpreter by yourself for your next visit? YesNo

6 NEUROSURGERY year month day Date of birth Address year month day Phone Do you have health insurance? Nationality YesNo Language What are your symptoms? headache dizziness nausea vomiting ringing in ears stiff shoulders numbness tremor unconsciouness difficulty in hearing difficulty in seeing difficulty in walking difficulty in limb movement others How long have you had these problems? Have you ever bumped your head? YesNo year month day Since year month day What part of your head? Was it caused by a traffic accident? frontbackright sideleft side YesNo A person with a headache is required to answer the following questions. What area of your head hurts? front back right side left side entire head Type of pain? throbbing sharp/severe like being struck with a hammer tingling pricking others When is the pain worst? morning noon evening all day Do you have any food or medication allergies? YesmedicationfoodothersNo Are you currently taking medication? YesIf you have any with you now, please show them to me.no Are you pregnant or is there a possibility of pregnancy? YesmonthsNo Are you currently breastfeeding? YesNo

7 What illnesses have you had in the past? stomach and intestinal disorder liver disease heart disease kidney disease tuberculosis diabetes asthma high blood pressure AIDS/HIV thyroid problems syphilis others Are you currently under medical treatment? YesNo Do you drink alcohol? Do you smoke? Have you ever had any operations? Have you ever had any trouble with anesthesia? YesNo YesNo Can you arrange an interpreter by yourself for your next visit? YesNo Yesml/a dayno Yescigarettes/a dayno

8 Date of birth Address PSYCHIATRY year month day Phone year month day Do you have health insurance? Nationality YesNo Language What are your symptoms? sleep is poor talk more than usual anxiety or panic attacks hear voices even though no one is around feel depressed low-spirited feel that someone is watching me spirit is too high become unconscious have a desire to die get excited easily be compelled to violence others How long have you had these problems? Since year month day Do you have any food or medication allergies? YesmedicationfoodothersNo Name of attendant Relationship with you familyfriendother Who suggested that you visit us today? youfamilyfriendpolicecolleague/co-worker other What is the purpose of today's visit? diagnosis treatment to be introduced to another institution other get medical certificate hospitalization get a second opinion Are you pregnant or is there a possibility of pregnancy? YesmonthsNo Are you currently breastfeeding? YesNo Do you have any other illnesses currently under treatment? Yesname of medical institutionno Are you currently taking medication? YesIf you have any with you now, please show them to me.no

9 What illnesses have you had in the past? dementia alcohol or drug dependence mood disordermaniamanic-depressive psychosisdepression panic personality disorder mental retardation schizophrenia others insomnia developmental disorder epilepsy ADHD Can you arrange an interpreter by yourself for your next visit? YesNo

10 Child s name PEDIATRICS year month day Date of birth year month day Age years-old Address Do you have health insurance? Phone YesNo Nationality Language What are your symptoms?(your child) fever( ) sore throat cough spasm moody/inactive irritable swelling headache abdominal pain chest pain rash stomachache vomiting loss of appetite(low milk intake) nausea insufficient weight gain diarrhea bloody stool others How long have you had these problems? Do you have any food or medication allergies? Yesmedicationeggmilkothers foodothersno Are you currently taking medication? YesIf you have any with you now, please show them to me.no What kind of internal medicine can you (he. she) take? syruppowdertablet or capsule How was the delivery? baby's weight gmother's age normal delivery abnormal delivery Caesarean section vaccination(history) Hib(Haemophilus influenzae type b) Pneumococcus polio DPT(triple combined vaccine) DPT-IPV (Diphtheria, Pertussis, Tetanus, Inactivated Poliovirus Vaccine) BCG Measles-Rubella VaccineMR) chicken pox mumps Japanese Encephalitis Rotavirus others What illnesses have you had in the past? rubella chicken pox measles asthma mumps whooping cough appendicitis MCLS(Kawasaki disease) exanthema subitum Japanese Encephalitis seizures others Are you currently under medical treatment? Since year month day YesNo Have you ever had any operations? Have you ever had any trouble with anesthesia? YesNo YesNo Can you arrange an interpreter by yourself for your next visit? YesNo

11 DERMATOLOGY year month day Date of birth Address year month day Phone Do you have health insurance? Nationality YesNo Language What are your symptoms? fever( ) pain itching burn rash eczema brusing mole liver spots athlete's foot oozing others How long have you had these problems? Since year month day Have the symptoms changed? YesNo Circle on the picture. Do you have any food or medication allergies? YesmedicationfoodothersNo Are you currently taking medication? YesIf you have any with you now, please show them to me.no Are you pregnant or is there a possibility of pregnancy? YesmonthsNo Are you currently breastfeeding? YesNo What illnesses have you had in the past? stomach and intestinal disorder liver disease heart disease kidney disease tuberculosis diabetes asthma high blood pressure AIDS/HIV thyroid problems syphilis others Are you currently under medical treatment? Have you ever had any operations? Have you ever had any trouble with anesthesia? YesNo YesNo YesNo Can you arrange an interpreter by yourself for your next visit? YesNo

12 OBSTETRICS and GYNECOLOGY year month day Date of birth Address year month day Phone Do you have health insurance? Nationality YesNo Language What are your symptoms? pregnancy irregular period vaginal discharge lower abdominal pain irregular genital bleeding polyps tumour vaginal itching uterine fibroids pap smear sterility anemia others Menstrual history When did your first period start? When was your menopause? Are your periods regular? ageyears ageyears YesNo Intervals Periods Menstrual flow 28days30daysdaysirregular days heavynormallight Do you suffer from any pain during your period? YesNo Date of your last period. History of pregnancy month day pregnancytimes deliverytimesnormaltimesabnormaltimes miscarriagetimesnatural abortiontimesabortiontimes others ectopic pregnancy hydatidiform mole Do you want to deliver your infant at this hospital? YesNo Do you have any food or medication allergies? YesmedicationfoodothersNo Are you currently taking medication? YesIf you have any with you now, please show them to me.no Have you ever had a pap smear? YesNo year month day What illnesses have you had in the past? stomach and intestinal disorder liver disease heart disease kidney disease tuberculosis diabetes asthma high blood pressure AIDS/HIV thyroid problems venereal disease others

13 Have you ever had any operations? Have you ever had a blood transfusion? YesNo YesNo Family's medical history : Fill out family's age and check() any diseases they had. father mother brothers sisters husband children age healthy not healthy hereditary disease high blood pressure diabetes cancer Can you arrange an interpreter by yourself for your next visit? YesNo

14 OPHTHALMOLOGY year month day Date of birth Address year month day Phone Do you have health insurance? Nationality YesNo Language What are your symptoms? right eye left eye both eyes tearing pain mucous discharge swelling itching something stuck in the eye blurred vision double vision sensitivity to light others How long have you had these problems? Since year month day Do you have any food or medication allergies? YesmedicationfoodothersNo Are you currently taking medication? YesIf you have any with you now, please show them to me.no Are you pregnant or is there a possibility of pregnancy? YesmonthsNo Are you currently breastfeeding? Have you ever had any trouble with anesthesia? YesNo YesNo What illnesses have you had in the past? stomach and intestinal disorder liver disease heart disease kidney disease tuberculosis diabetes asthma high blood pressure AIDS/HIV thyroid problems syphilis others Are you currently under medical treatment? YesNo Does anyone in your family have eye diseases? Yeswho?what? No Can you arrange an interpreter by yourself for your next visit? YesNo

15 OTOLARYNGOLOGY (EAR,NOSE AND THROAT) year month day Date of birth Address year month day Phone Do you have health insurance? Nationality YesNo Language What are your symptoms? I have a fever.( ) My head feels heavy. I have a headache. ear problems right left both earache discharge ringing in the ears wax build up feel dizzy difficulty in hearing nose problems plugged ears stuffiness runny nose sneezing bleeding snoring inability to smell throat ploblems sore tongue sore throat coughing phlegm feeling as if something is stuck in throathoarseness difficulty in swallowing swollen face/neck others How long have you had these problems? Do you have any food or medication allergies? YesmedicationfoodothersNo Are you currently taking medication? Since year month day YesIf you have any with you now, please show them to me.no Are you pregnant or is there a possibility of pregnancy? YesmonthsNo Are you currently breastfeeding? Do you drink alcohol? YesNo Yesml/a dayno Do you smoke? Have you ever had any operations? Have you ever had a blood transfusion? Have you ever had any trouble with anesthesia? Yescigarettes/a dayno YesNo YesNo YesNo Can you arrange an interpreter by yourself for your next visit? YesNo

16 Date of birth Address DENTISTRY year month day Phone year month day Do you have health insurance? Nationality YesNo Language What are your symptoms? toothache filling fell out gums hurt cavity new dentures crooked teeth broken dentures teeth check-up teeth cleaning bad breath others Do you have any food or medication allergies? YesmedicationfoodothersNo Are you currently taking medication? YesIf you have any with you now, please show them to me.no Have you ever had any trouble with anesthesia? Have you ever had a tooth removed? YesNo YesNo Are you pregnant or is there a possibility of pregnancy? YesmonthsNo Are you currently breastfeeding? YesNo What illnesses have you had in the past? stomach and intestinal disorder liver disease heart disease kidney disease tuberculosis diabetes asthma high blood pressure AIDS/HIV thyroid problems syphilis others Are you currently under medical treatment? YesNo Your preferences for treatment I want to have all of my teeth problems fixed. I prefer to have only my painful teeth treated right now. I ll pay the full amount. I want to have treatment within the limits of my health insurance coverage. I want to decide the treatment after consulting with the doctor. Can you arrange an interpreter by yourself for your next visit? YesNo

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