Web問診表（英語）

・This is the WEB medical form page of Ryuoh Family Clinic.

・Now, we can't provide emergency support, such as infection diseases. We can reply on our business day only.

・必須 in red square means you have to fill out the blank to send.

・After filling in the form, please press the button of 確認画面へ (= go to confirmation page) at the bottom.
・After checking your answers on the confirmation page, please press the button of この内容で送信する (= send the contents) at the bottom.

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Name必須

Sex必須: M

F

Age必須: ex: 55 years old

Body weight (kg): Please enter in case of infant.

Birthday(mm/dd/yyyy)必須: ex: 08/28/2012

Phone number必須: ex: +81 552762300

Email address: If you want to contact us by Email, please enter your Email address.

Address: 郵便番号

都道府県

市区町村

番地以降

建物名室番

If you live in Japan, please write your address. ex: 4000013 Yamanashi, kai city, tomitakeshinden 1757-1

Reservation date: ex: 08/28/2012
You have to make a reservation to visit. If you have the appointment, please enter your appointment date.

Preferred date and time zone to visit: ex: 08/28/2012 AM
If you don't have the appointment, please enter your preferred date and time zone. We call you or send Email to you later to make a reservation. Note: First time visit person and unstable medical condition person can't reserve on Saturday.

History of present illness必須: Please describe your symptoms in detail.

Past history of disease or injury 必須: ex: hypertension, gout

Medicine必須: ex: Amlogipine 5mg after breakfast

Upload of medicine information

ファイル添付またはここにファイルをドロップ

If you have any informations of your recent medicine, please take a picture and upload the image.

Allergy必須: ex：Amoxicillin, eruption

Alcohol 必須: ex：beer 350ml everyday

Smoking必須: ex：20 cigaretts a day for 30 years

Only woman answer, please: Pregnant
Lactating
Neither

Upload of health insurance card

ファイル添付またはここにファイルをドロップ

Please take a picture of health insurance card and upload, if you have.

Please bring your health insurance card, if you have.必須: OK

We sometimes need to confirm it in case of unclear image.

Please bring your notebook about health, if you have.必須: OK

ex: record of vaccines, medicines, medical checkup

Upload of any health informations

ファイル添付またはここにファイルをドロップ

If you have recent records of checkup and so on, please take a picture and upload before medical examination.

Free description: If you have any requests, please write.

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