| DATE OF MEDICAL TREATMENT: HEISEI YEAR / MONTH
/ DAY |
| ADDRESS : TEL: |
| FULL NAME / WEIGHT kg
/ TEMPERATURE ℃ |
| BIRTH DATE AGE Name of person filling out form |
| PLEASE CIRCLE YOUR RESPONSES FOR THE FOLLOWING
QUESTIONS: |
☆IS THERE ANYTHING THAT WOULD CAUSE YOU A RASH?
MEDICINE: FOOD: OTHER: |
YES
|
NO
|
| ☆HAVE YOU EVER BEEN TOLD YOU HAVE ASTHMA? |
YES
|
NO
|
☆IS THERE ANYTHING THAT WOULD CAUSE YOU HIVES?
MEDICINE: FOOD: OTHER: |
YES
|
NO
|
| ☆HAVE YOU EVER HAD A BAD REACTION TO PENICILLIN SHOTS OR PILLS? |
YES
|
NO
|
| ☆HAVE YOU EVER HAD ANY ADVERSE SIDE EFFECTS FROM ANY MEDICATION?
NAME OF MEDICATION: |
YES
|
NO
|
| ☆ARE YOU TAKING ANY OTHER MEDICATION AT THE PRESENT TIME? NAME
OF MEDICATION: |
YES
|
NO
|
| ☆HAS YOUR CONDITION EVER BECOME WORSE WHILE TAKING ANY CERTAIN
REMEDY? NAME OF REMEDY: |
YES
|
NO
|
| ☆HAVE YOU EVER BEEN TOLD BY A DOCTOR THAT YOU MAY HAVE A TENDENCY
TOWARD ANY SPECIAL PHYSICAL CONDITION? |
YES
|
NO
|
| ☆HAVE YOU EVER HAD A SERIOUS ILLNESS? (SURGERY OR HOSPITALIZATION)
ILLNESS: |
YES
|
NO
|
| ☆IF YOU ARE A WOMAN, ARE YOU PREGNANT? |
YES
|
NO
|
|
☆YOUNG CHILDREN : IF YOUR CHILD HAS CONTRACTED
ANY OF THE FOLLOWING ILLNESS, PLEASE CIRCLE THEM.
MEASLES RUBELLA CHICKENPOX MUMPS AUTOTOXEMIA
|
