Transcription of Medical Questionnaire (Internal Medicine)/
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Example: dental hygienist
Medical Questionnaire (Internal Medicine)/
english / .. ID . Medical Questionnaire (Internal Medicine)/ . Please check the appropriate . year month day Patient name/ Date/ . / / / . Date of birth/ year/ month/ day/ Sex/ Male/ Female/ . Height and weight/ cm kg Age/ years old/ . Language/ Nationality/ . Living condition/ . With family member(s) who require nursing care/ Have young children/ . Aged household/ Living alone/ Single parent/ . Other/ ( ). Employment/ . Full-time/ Part-time/ Self-employed/ . Retired/ Unemployed/ . What symptoms do you have?/ . Headache/ Dizziness/ Dry mouth/ . Sore throat/ Cough/ Palpitation/ . Chest pain/ Chest discomfort/ Stomachache/ . Nausea/ Vomiting/ Shortness of breath/ . Diarrhea/ Abdominal bloating/ Abdominal pain/ . Bloody stools/ Fever/ Rash/ . High blood pressure/ Cannot sleep/ Lack of energy/ . Easily fatigued / Weight loss/ Loss of appetite/.
English/英語 患者氏名： 患者ID ： 1 / 2 内科 問診票 ： 2014年3月初版 *Please fill in the reverse side of the all pages as well, where necessary./ ※裏面もご記入ください。
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