Web問診表（英語）

・This is the WEB medical form page of Ryuoh Family Clinic. 
・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. 
ex: 55 years old
Please enter in case of infant. 
ex: 08/28/2012
ex: +81 552762300
If you want to contact us by Email, please enter your Email address. 
If you live in Japan, please write your address. ex: 4000013 Yamanashi, kai city, tomitakeshinden 1757-1
ex: 08/28/2012   
You have to make a reservation to visit. If you have the appointment, please enter your appointment date. 
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. 
Please describe your symptoms in detail. 
ex: hypertension, gout
ex: Amlogipine 5mg after breakfast
Add files Drop down or upload files here
    If you have any informations of your recent medicine, please take a picture and upload the image. 
    ex：Amoxicillin, eruption
    ex：beer 350ml  everyday
    ex：20 cigaretts a day for 30 years
    Add files Drop down or upload files here
      Please take a picture of health insurance card and upload, if you have.
      We sometimes need to confirm it in case of unclear image. 
      ex: record of vaccines, medicines, medical checkup 
      Add files Drop down or upload files here
        If you have recent records of checkup and so on, please take a picture and upload before medical examination.  
        If you have any requests, please write.
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