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
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
Initial Health History
Questionnaire
Please fill in this form before your initial appointment.
-
age 0 - 2
-
age 3 - 12
-
Adult
Initial Health History Questionnaire (age 0-2)
*
は必須フィールドです
Name
*
最初
最新
Preferred time and date
*
Email address
*
Reason for this appointment for your baby.
*
When did you notice it?
*
How did it start?
*
Please choose from below
Sudden with an event
Sudden without any event
Gradually
Others
Has your child been seen by Dr. with this condition?
*
Please choose from below
Yes
No
About General Health of your child
How many hours does you child sleep at night?
*
How many hours does your child take a nap?
*
Does your child have a preferred sleeping postion
*
Please choose from below
Yes
No
Unknown
Does you child go to sleep easily?
*
Please choose from below
Yes.
Sometimes difficult to go sleep
Sometimes easy to go sleep
No
Does you child have a preferred sleeping position?
*
Does your child have any feeding difficulties?
*
Please choose from below
Yes
No
Does your child have any feeding difficulties?
*
Please choose from below
Yes
No
Yes, but in the past
Dose your child have any skin rashes?
*
Please choose from below
Yes
No
Had your child had any falls or trauma?
*
Please choose from below
Yes
No
If yes, please describe the trauma and date it occurred?
*
Has your child ever had a broken bone?
*
Please choose from below
Yes
No
Unknown
Has your child ever had ear infections?
*
Please choose from below
No, never.
Yes, a few times.
Yes, rarely
Yes, often
Has your child ever had colic?
*
Please choose from below
Yes
No
Has your child had asthma?
*
Please choose from below
No
Yes
Is your child allergic to anything?
*
Is your child currently receiving any medications?
*
Please choose from below
Yes
No
Has your child ever been to an emergency room?
*
Please choose from below
Yes
No
If yes, when and why?
*
Any additional comments or concerns?
*
Thank you for completing this questionnaire!
Please press the send button.
Send
Initial Health History Questionnaire (age 3- 12)
*
は必須フィールドです
Name
*
最初
最新
Preferred time and date
*
Email address
*
Please describe your child problem or concern
*
When did it start?
*
How did it start?
*
Please choose from below
Sudden with an event
Sudden without any event
Gradually
Others
When does your child complain the problem
*
Since it began, is your child's problem
*
Please choose from below
improving
getting worse
no change
others
Has your child had similar condition in the past?
*
Has your child been seen by Dr. with this condition?
*
Please choose from below
Yes
No
About General Health of your child
How many hours does you child sleep at night?
*
Does your child have a preferred sleeping postion
*
Please choose from below
Yes
No
Unknown
Does you child go to sleep easily?
*
Please choose from below
Yes.
Sometimes difficult to go sleep
Sometimes easy to go sleep
No
Does you child have a preferred sleeping position?
*
Does your child have any feeding difficulties?
*
Please choose from below
Yes
No
Had your child had any falls or trauma?
*
Please choose from below
Yes
No
If yes, please describe the trauma and date it occurred?
*
Has your child ever had a broken bone?
*
Please choose from below
Yes
No
Unknown
Has your child ever had ear infections?
*
Please choose from below
No, never.
Yes, a few times.
Yes, rarely
Yes, often
Has your child had asthma?
*
Please choose from below
No
Yes
Any additional comments or concerns?
*
Thank you for completing this questionnaire!
Please press the send button.
Send
Initial Health Questionnaire (Adult)
*
は必須フィールドです
Name
*
最初
最新
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
