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* 1. 基本情報(全てお答えください)/Personal Information(All are required information)

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* 2. お困りの症状を教えてください。/What brings you here?

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* 3. それはいつからですか?/ Since when are you suffering?

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* 4. これまでにかかった病気はありますか?/ Please write down your past medical history

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* 5. 薬や食べ物でアレルギーはありますか?/ Do you have allergies? or Have you ever had allergic reaction to any drugs or food?

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* 6. 現在飲んでいる薬はありますか?/ At this point, are you taking any of medications?

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* 7. 現在治療中の病気はありますか?/ Are you having any diseases currently under treatment?

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* 8. これまでに手術を受けたことはありますか?/ Have you ever had surgeries?

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* 9. その他、ご質問・ご希望等ありましたらご遠慮なく教えてください。/ If you have any questions or request, please do not hesitate to tell us.

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* 10. 【優先診療やキャッシュレス決済をご希望の方】迅速な診療体制維持と患者様の多様なニーズにお応えするために、当院では下記の「予約料(優先診療やキャッシュレス決済に対応)」を設けております。 / To quick consultation and fit patient's multiple needs, we have an option. If you are willing to pay "Reservation Fee ", priority doctor consultation and credit card payment are available.(Only for Japanese health-insurance user)

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