健康診断業務 日本語英語 ... - health-uv.umin.ac.jp

1 50 50 1 Name Student ID Date of birth Phone number This is a questionnaire about the status of your health and lifestyle.

2 The information you provide will be kept confidential and will not be shared with anyone. We may use this information to support your health on campus. The data may also be used for health status and lifestyle research studies of university students. However, personal information will not be disclosed and will be used for statistical analysis only. The research results may be presented and published. We will use the data provided in the questionnaire only for improving the health status and lifestyles of students. ( ) Please check ( ) the most appropriate option/s. Do you have a past history of any illness/illnesses?

3 Yes No Are you currently under any medical treatment or medical follow-up Yes No If yes, what illness(es) did you have? heart disease including cardiac surgery arrhythmia 2 pulmonary tuberculosis pneumonia pneumothorax asthma hepatitis diabetes iron deficiency anemia Ig nephritis including nephrosis collagen disease/rheumatism thyroid disease including Graves disease and Hashimoto's thyroiditis appendicitis atopic dermatitis allergic rhinitis including pollen allergy epilepsy psychiatric illness including depression and sleep disorder / pervasive development disorders (Asperger s)

4 Disorder, learning disorder, and attention deficit/hyperactivity disorder) others details: Do you have any disability? Yes No If yes, what is the disability? visual disorder including amblyopia auditory disorder limb movement disorder/locomotive disorder visceral disease internal organ disease others details: Do you need any support on campus on account of an illness or physical disability? Yes No If yes, for what reason/s do you need support? need to visit the hospital frequently 3 need to use a wheelchair or other perambulatory aids inability to fully participate in physical education classes difficulty in seeing characters/letters on the blackboard / have a hearing problem cannot participate in school activities owing to anxiety and fear Do you have any anxiety regarding your new campus life?

5 I went through a period when I could not attend school for more than 30 days at a stretch I have anxiety about making friends because of a past experience of having been bullied Where do you reside currently? at home apartment/boarding house dormitory others 1 How long do you sleep on weekdays? 5 less than 5 hours 6 6 hours 7 hours 8 8 hours 9 9 hours 10 10 hours 11 more than 11 hours Were you a member of any club/circle in your junior and/or senior high school days?

6 No a member of sports club/circle 4 a member of culture club/circle a member of sports and culture club/circle 1 1 How much time do you spend on the Internet on an average per day? do not access 1 less than 1 hour 1 2 1 2 hours 3 4 3 4 hours 5 more than 5 hours 1 Do you play any games on the Internet? If yes, how long do you play on an average per day? do not play 1 less than 1 hour 1 2 1 2 hours 3 4 3 4 hours 5 more than 5 hours Smoking I have never smoked. I smoke. I have quit smoking.

7 I want to quit smoking. 1 Number of cigarettes smoked per day I have been smoking for years. Alcohol I do not drink alcohol. I drink alcohol. I drink day(s) per week. I drink go per day. 1 180ml 1 500ml 35 80ml 1 60ml 2 240ml go=One serving of sake (180mL. or oz) = One medium bottle of beer (500mL) = Distilled spirits of 35 (80mL) = Two fingers of whisky (60mL) = Two glasses of wine (240mL) Current subjective symptoms 5 Eye fatigue Blurred vision Tinnitus Dizziness vertigo Dizziness on standing up Hoarse voice Frequent coughing Frequent sputum Bloody sputum Palpitations (rapid heart rate)

8 Frequent shortness of breath Irregular pulse Pain or chest oppression Loss of appetite Frequent stomachacha Frequent nausea and vomiting Frequent heartburn and burping Frequent diarrhea Tendency to be constipated Thin or hard stool Black stool Bloody stool Hemorrhoids Difficulty of swallowing Upper abdominal pain Lower abdominal pain Difficulty in urinating 10 Frequent urination ; 10 times or more per day Feeling of residual urine Shoulder neck stiffness or pain Lower back pain lumbago Numbness of the hands or feet Joint pain Headache or heaviness of the head Edema in the hands or feet Tendency to get tired easily 6 Difficulty falling sleep insomnia Continuous thirst Waking up very early in the morning Depressed or irritated Sudden weight loss Allergy Impaired tongue movement Nothing in particular To be completed only by females I am pregnant or I might be pregnant right now.

9 I am on period now. I have irregular periods. I am currently breastfeeding. Weight 20 10kg Since age 20 years, my body weight increased by 10kg ( ) or more. 1 3kg I have gained or lost more than 3kg ( ) in the past year. Eating habits I frequently eat sweet food. I frequently eat salty food. I frequently eat oily food. Not applicable Diet style 3 I eat snacks after dinner, 3 times or more each week. 3 I skip breakfast 3 times or more each week. 2 3 I eat dinner within 2 hours of going to sleep, 3 times or more each week.

10 Compared to other people, I eat faster at an average speed slower Exercise 7 1 30 2 1 I have been exercising at least twice a week (at least 30 min per session of light sweating) for 1 year. 1 1 I walk or exercise everyday for at least 1 hour. I walk faster than other people of my sex and age. Sleep I get sufficient sleep every day. Improvement of lifestyle such as exercising and eating I am not going to improve my lifestyle. 6 I have already improved my lifestyle (I started less than 6 months ago). 1 I am going to improve my lifestyle (within 6 months).