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ガク関節ケア
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為になる
ストレス
ホーム
軸
サービス
サービス・一般
赤ちゃん
ガク関節ケア
質問 FAQ
English
Testimonials
為になる
ストレス
Initial Health History
Questionnaire
Please fill in this form before your initial appointment.
- age 0 - 2
- age 3 - 12
-
Adult
Initial Health Questionnaire (Adult)
*
必須フィールドを表示
Name
*
名
姓
Preferred date and time
*
email address
*
Please describe your major problem
*
When did it start?
*
How did it start?
*
Sudden with an event
Sudden without any event
Gradually
Others
Describe your current pain/ symptoms.
*
Achy
Sharp/ stabbing
Dull
Burning
Throbbing
Weakness
Tingling
Numbness
Others
How often are your symptoms present?
*
Constantly
Daily
Weekly
Monthly
Sometimes
Others
Since it began, is your problem :
*
Improving
Getting worse
No change
Others
Have you ever had same problem before? (If yes, when?)
*
Does your pain radiate to other area of your body?
*
What makes the problem better?
*
What makes the problem worse？
*
What is your second complain?
*
Past health history: Hospitalisations
*
Yes
No
If you answered yes, why were you hospitalized and when?
*
Past health history: vehicle accident
*
Yes
No
Fracture bones
*
Yes
No
Have you ever had any of the following conditions?
*
Stroke
Heart disease
Asthma
Cancer
Anxiety
Depression
What is your blood pressure
*
Low
Normal
Controlled with medication
High without medication
others
unknown
How often do you have headache?
*
None
Rarely
Monthly
Weekly
Daily
Any additional comments or concerns?
*
Thank you for completing this questionnaire!
Please press the send button.
Send
☎
080-3979-1518
