書類 · 日本語
診察予約表
Appointment request and pre-consultation information form.
- Form type
- pl-shinsatsu
- Language
- Japanese (日本語)
- Archive source
- AMDA-IMIC Japan forms library, 2013–2024
About This Form
This page documents the 診察予約表 as provided in Japanese through AMDA-IMIC's multilingual forms library. The form is used for: appointment request and pre-consultation information form..
Making medical appointments in Japan involves providing standard demographic and insurance information before the visit date is confirmed. For foreign residents, the consultation appointment form serves double duty: it both requests the appointment slot and captures the language assistance needs required for the visit. AMDA-IMIC coordinated with clinics to ensure the pre-consultation form was available in the patient's preferred language, reducing the friction of first contact with an unfamiliar healthcare provider.
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).
- Patient full name and date of birth
- Nationality and current residence address
- Contact telephone number
- Primary language and language assistance needed (yes/no)
- Health insurance type and card number
- Department requested (internal medicine / pediatrics / orthopedics / obstetrics / other)
- Preferred appointment date and time (first and second choice)
- Chief complaint or reason for visit
- Duration of symptoms
- Current medications
- Previous visits to this clinic (yes/no, date if yes)
- Allergies to medications (yes/no, specify if yes)
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.