Transcription of Medical Questionnaire (Obstetrics and Gynecology)/
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Medical Questionnaire (Obstetrics and Gynecology)/
english / .. ID . Medical Questionnaire (Obstetrics and Gynecology)/ . 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 brought you here today?/ . Pregnancy/ Abnormal menstruation/ Vaginal discharge/ . Lower abdominal pain/ Irregular genital bleeding/ Polyps/ . Ovarian cysts/ Genital itchiness/ Uterine fibroids/ . Cancer screening/ Infertility/ Anemia/ . Fits/ Other/ ( ). When did the symptoms start?
English/英語 患者氏名： 患者ID ： 1 / 3 産婦人科 問診票 ： 2014年3月初版 *Please fill in the next page(s) as well./ ※次のページもご記入ください。
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