書類 · 日本語
簡単問診票
Simplified pre-consultation intake form submitted before an appointment.
- Form type
- ezmonshin
- Language
- Japanese (日本語)
- Archive source
- AMDA-IMIC Japan forms library, 2013–2024
About This Form
This page documents the 簡単問診票 as provided in Japanese through AMDA-IMIC's multilingual forms library. The form is used for: simplified pre-consultation intake form submitted before an appointment..
Pre-consultation intake became more common in Japan's healthcare system following the expansion of online appointment booking. The simplified intake form (簡単問診票) is designed to be completed at home before the visit, allowing the clinic to prepare appropriately and reducing waiting room processing time. For foreign patients, completing this form in their own language in advance is particularly valuable, since the alternative — attempting to complete a Japanese-language form in the waiting room — often results in incomplete data and delays the consultation.
For the original administrative forms in active use, contact the relevant Japanese institution directly — a hospital, employer, local health center, or labor bureau — depending on which form is needed. This reference documents the structure and purpose of the forms as they were used during the 2013–2024 period when AMDA-IMIC was operating.
Form Sections and Fields
The following sections and fields appear in the Japanese version of this form. Field labels are rendered here in English for reference; the original form presents them in Japanese (日本語).
- Full name and date of birth
- Contact telephone number
- Today's main concern (free text, brief description)
- Duration of current symptoms
- Severity on a scale of 1–10
- Worsening factors (activity / rest / time of day / other)
- Relieving factors
- Fever (yes/no; temperature if known)
- Previous treatment for this issue (yes/no; what was done if yes)
- Current medications (name and dose)
- Known allergies
- Language assistance needed at appointment (yes/no)
- Preferred appointment time
How to Obtain This Form
The forms documented on this site were originally distributed by AMDA-IMIC through its consultation service and language-specific subdomains. Since the center closed in 2024, the forms are no longer distributed through that channel. Equivalent forms for current use are available from the relevant Japanese institution: municipal health centers issue administrative forms, hospitals provide their own registration and appointment materials, and the Labor Standards Inspection Office supplies labor insurance documentation.