Preliminary Examination Form
This is the preliminary examination form for Kinshicho Station Building Dental Clinic. Please answer each question before the appointment.
If you’d like to write in the paper form, please visit us 15 minutes before your appointment time.
There are three major sections in this questionnaire – pre-examination, health lifestyle and dental treatment. Please answer each question and submit.

If you are good at Japanese, please click here  ：　https://forms.gle/rjgt53iTe9tm7zwy7

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Name (First name, Last name)
Name in Katakana or Nickname if available
sex
Clear selection
お誕生日について　
birthday
Birthday（YYYY/MM/DD)
If you are using the smartphone, please tap the year and select.
MM
/
DD
/
YYYY
Postal code
ex）270-2253　
現在のお住まいをお尋ねします
I will ask you about your current residence in Japan
ご連絡先の記入
Enter contact information
Current address in Japan
ex）3-14 Kotobashi, Sumida-ku
Cellphone number
ex）000-0000-0000 （Please put a hyphen）
Mail address
We may send an e-mail for reservation confirmation / sudden closure notification in the case of disaster like earthquake etc. 4184abc＠gmail.com 
Japanese skill.
Do not speak Japanese
Speak Japanese fluently
Clear selection
What made you come to this clinic?
おもにいらっしゃるきっかけとなったものは　なんでしょうか？　
How did you find out about this clinic?
Referral friend's name
ex）Mr.Taro KIMURA
How were you recommended by the referral?
予診票
本日の来院理由についてお尋ねいたします
What happened?
Please check the appropriate items. Multiple answers are possible.
When was the last time you went to the dentist?
お体についておたづね致します
現在のお体の状態　病院の通院などをお聞きいたします
持病/疾患などありますか？ Do you have any chronic illness / disease?
Please check the appropriate items. Multiple check is possible
Do you have an infectious disease？
過去に感染症になられて医師から診断されたことがありますか？ Have you ever been diagnosed with an infectious disease?
Clear selection
通院の場合どちらからですか？
Where do you mostly come from to this clinic?
Clear selection
When is the day of the week unavailable?
通院に不可能な曜日にチェックをしてください！　何曜日でも来れる方はなし　When is the day of the week unavailable? Please check the days of the week that are not available! 　If you could come anytime, check「NO」
Conditions for coming to the clinic.
Conditions for coming to the clinic.
麻酔の注射や歯を抜歯した際に何か異常がありましたか？Have you ever had any problems with anesthesia injections or tooth extractions?
Have you ever had any problems with anesthesia injections or tooth extractions?
Clear selection
ありの方はその時どのようになりましたか？If you chose 「YES」, What happened to then?
なしの方は飛ばしてください    If you chose 「NO」, please skip here.
Clear selection
Do you have any drug or food allergies?
ありの方は、次の質問も答えてください　　If you have some allergies, please answer the following questions.
Clear selection
What happens when allergic symptoms occur?
何のアレルギーでしょうか？そのとき起ったときのことを教えてください　What happens when allergic symptoms occur? What allergies caused it?　
現在、通院中の病院はありますか？
Are there any hospitals you are currently visiting?
Clear selection
疾患名 Name of disease
医師から診断されている病名をおたづね致します I will ask you for the name of the disease diagnosed by your doctor.
病院名 The name of the hospital
かかりつけの医院はございますか？ Do you have a primary doctor in Japan?
現在お飲みになっているお薬はございますか？Are you currently taking any medications?
Clear selection
ありの方は、常用薬名を教えてください。If you have one, please tell me the name of your regular medicine.
お薬手帳は受付にご提出ください　コピーを採らせていただきます Please submit the medicine notebook to the receptionist. I will make a copy.
今回の診療に関するご希望を選択ください。Please select your preference regarding this medical treatment.
担当医　担当衛生士の希望がありましたらご記入お願いします　If you have a doctor or hygienist you want, please write it down.
ex) Dr. Miyazaki hope
当院では初回とメンテナンス前に唾液検査を用いてメンテナンスプログラム実行をしてよろしいでしょうか？　We carry out a maintenance program using saliva testing for the first time and before maintenance. Can you accept it?
唾液検査：初回5,000円 ２回目3,000円 　幼児2,000円/1検査　診療室でもう一度確認させていただきます　Saliva test: 1st.￥ 5,000,   2nd  ￥3,000   Infant ￥2,000  /1 exam.   We will check again in medical office.
I understand you
We check the insurance card at the beginning of every month. It will be a 100% burden if there is no submission (with a refund after insurance card confirmation)

If you are new to the internet, please call us for reservation.

If you do not present your health insurance card, the initial examination fee is 10,000 yen. The reexamination fee is 5,000 yen.

On the day or cancellation without notice, it will be difficult to make the next reservation. We have you change reservation by the day before on the occasion of change

In the case of withdrawal such as temporary lid during treatment period, re-examination fee will be charged when coming to the hospital again

As we take medical safety management measures in this hospital, we may not be able to see even if doctor is present if it is not sterile apparatus
We apprecaite if you accept it ☑️
A few more, please proceed
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