Medical questionnaire

First Name

Last Name

Country

Address

Height

Weight

Gender

Male

Female

Date of Birth

Phone number

Email Address

Occupation

Languages Spoken

English

Chinese

Japanese

Others

Please fill in the relevant boxes.

1. Could you kindly provide more context or background information regarding your request?

2. Could you please describe the symptoms that have appeared?

3. Could you please let us know when the symptoms began?

4. Have you ever been diagnosed with any condition?

5. Have you ever had surgery?

6. Do you wear contact lenses?

7. Are you currently seeing another clinic?

8. Are you allergic to any medications, pollen, or foods?

9. Are you currently undergoing treatment for any medical conditions?

Hypertension

Diabetes

Arrhythmia

Heart Disease

Asthma

Rheumatism

Cataracts

Glaucoma

Graves’ Disease

Hashimoto’s Disease

HIV

Syphilis

Hepatitis B

Hepatitis C

Others

10. What medications are you taking?

11. For female patients: Are you currently pregnant or breastfeeding?

Questions 12 and 13 are essential and must be verified when providing guidance for general anesthesia surgeries in Japan.

Depending on the situation, inaccurate information may lead to the cancellation of the surgery based on the doctor's judgement on the day.

Therefore, please provide accurate details.

12. For female patients: Are you currently taking low-dose birth control pills?

13. Are you currently taking antithrombotic drug?

14. How did you come to know about our clinic?

15. What is the estimated cost of the surgery?

USD

16. Do you have any preferences for the date of the online meeting?

17. What is the symptom you absolutely want to address?

18. If possible, are there any other symptoms you would like to address?

19. Is there anything else you are concerned about or would like to share with the doctor?

Please note that for the advancement of medical science, patient care and surgical records may be used for conference presentations and publications.