Describe the main symptom or concern in your own words — for example, 'knee pain for 2 weeks' or 'annual physical.' Keep it brief; the provider will ask follow-up questions.
Common options include diabetes, hypertension (high blood pressure), asthma, heart disease, cancer, thyroid disease, depression or anxiety, and arthritis. Check any you have been formally diagnosed with by a provider.
List each prescription and over-the-counter medication you take regularly. Include the name and dose if known. A separate Medication and Allergy List form often captures this in more detail.
Note any symptoms that have persisted for weeks or months, even if you are not sure of the cause. This helps the provider decide which areas to examine or test.
Include overnight hospital stays for any reason — illness, injury, or mental health — with the approximate year. Routine outpatient visits do not need to be listed here.
Include serious illnesses such as a heart attack, stroke, or major infection that required extended care, even if they did not result in surgery or hospitalization.
Family history of heart disease, stroke, or cancer
心疾患・脳卒中・がんの家族歴
Note which relatives were affected — for example, 'mother, breast cancer' or 'father, heart attack at age 50.' Focus on parents, siblings, and grandparents. If you do not know, write 'unknown.'
Family history of diabetes or inherited conditions
糖尿病または遺伝性疾患の家族歴
List conditions common in your family, such as type 2 diabetes, high cholesterol, kidney disease, or genetic disorders. Note which relative had the condition.
Select: never smoked, former smoker (quit date if known), or current smoker (packs per day or type — cigarettes, e-cigarettes, cigars). Smoking affects many health conditions and medications.
Indicate: none, occasional (a few drinks per month), moderate (up to one drink per day), or heavy (more than one drink per day). Alcohol interacts with many medications and affects health screenings.
Select: sedentary (little to no regular exercise), light (1–2 days per week), moderate (3–4 days per week), or vigorous (5 or more days per week). Note the type of activity if you wish.