しば胃腸こうもんクリニック SHIBA INTERNATIONAL ANUS CLINIC ID 平成２６年　月　日　フ　リ　ガ　ナ氏　名（男　・　女） ENGLISH 生年月日郵便番号 M(明治） S（昭和） T(大正） H(平成）〒 ― 年月日　（才）（ TEL, Simple　）住　所緊急連絡先（）（）勤務先会社連絡先Ｅメールアドレス w/I, ☆当院はどのようにお知りになりましたか？１）２）３）４）５) 知り合いから当院の前を通り知ったハガキ・チラシ・ハント新聞看板　◎地下鉄(三田線・浅草線・田町駅連絡路) ◎消火栓 ◎電柱インターネット(スマートフォン又は、iPhone・パソコン) ６) ７) 地下鉄ガラスシートマップ(二つ折、四つ折) (芝、芝浦、田町、白金) ◎今日はどうなさいましたか？（ ) ・アレルギーはありますか？はい・いいえ　：はいの方　→　アレルギーの種類（）・現在治療中の病気があればご記入ください。 ( ) ・服用中のお薬があればご記入ください。 ( ) ・過去に治療なさった病気、手術があればご記入ください。（　年　月/病院名）（　年　月/病院名） Clinic ID / /2014 Please fill out and make circles following information to help us to know your condition? Name Gender : Male or Female Date of Birth / / ( ) Age Address:〒 Phone number How did you know us? 1 Someone told you about us 2 Through our Home page in Web site. If so, what words did you enter for search? 3 Passed our clinic and found us. 4 Sign in Subway street , or in the train , or in the pole in back street , or in the red pole of fire department 5 Post card 6 Flyer ( Japanese or Korean ) Have you ever had any allergic reaction? reaction If so, to what? What brought you here? Do you have any medical problem? If so, what kind of medical problem? Do you take any medication? If so, what are those? Have you ever had any serious illness? What was it? Have you ever had any surgery? What kind of surgery? When was it? For those who have anus problem: 1 Do you feel pain as bowel movement? 2 Do you see any blood as bowel movement? Yes or No Yes or No 3 Do you feel something coming out as bowel movement? Yes or No 4 Do you often have diarrhea or constipation? If Yes, Which? diarrhea or constipation Shiba International Anus Clinic