Medical questionnaire

First Name

Last Name

Country

Address

Height

Weight

Gender

Male

Female

Date of Birth

Phone number

Email Address

Occupation

Languages Spoken

English

Chinese

Japanese

Others

Please fill in the relevant boxes.

1. Could you tell us about the background of your request?

2. Please describe in detail the symptoms you are experiencing.

3. When did your symptoms start and how do they affect you?

4. Have you ever been diagnosed with any illness?

5. Have you ever undergone any surgeries?

6. Do you wear contact lenses?

7. Are you currently seeing another clinic?

8. Do you have any allergies to medications, pollen, food, etc.?

9. Are you currently being treated for any illness?

Hypertension

Diabetes

Arrhythmia

Heart Disease

Asthma

Rheumatism

Cataracts

Glaucoma

Graves’ Disease

Hashimoto’s Disease

HIV

Syphilis

Hepatitis B

Hepatitis C

Others

10. Are you currently taking any medication?

11. (For women) Are you currently pregnant or breastfeeding?

Questions 12 and 13 are essential and must be verified when providing guidance for general anesthesia surgeries in Japan.

Depending on the situation, inaccurate information may lead to the cancellation of the surgery based on the doctor's judgement on the day.

Therefore, please provide accurate details.

12. (For women) Are you currently taking low-dose birth control pills?

13. Are you currently taking any antithrombotic medication?

14. How did you learn about our clinic?

15. How much is the estimated cost of the surgery?

USD

16. Do you have any preferred dates for an online consultation?

17. Are there any symptoms that you absolutely want to resolve?

18. Are there any other symptoms you are concerned about?

19. Do you have any other concerns or anything else you'd like to share with the doctor?

Please note that for the advancement of medical science, patient care and surgical records may be used for conference presentations and publications.