Japanese Medical Intake Forms: 問診票, 既往歴, アレルギー, 同意

Core examples: 問診票, 既往歴, アレルギー, 同意, 症状, 服薬中, 妊娠, 家族歴, 署名, 緊急連絡先.

A checkbox can change the conversation

A clinic form asks:

症状はいつからですか。 既往歴はありますか。 アレルギーはありますか。 服薬中の薬はありますか。 同意しますか。

The questions look simple, but the answers guide clinical conversation. A misunderstood checkbox can affect medication, testing, consent, or urgency.

The key principle is:

Medical intake forms turn patient experience into categories clinicians can act on.

This is a language-literacy article, not medical advice. For real medical concerns, ask qualified professionals and request interpretation support when needed.

問診票: medical questionnaire

問診票

means medical intake questionnaire.

It usually asks about:

• current symptoms,
• onset,
• severity,
• medical history,
• allergies,
• current medication,
• pregnancy,
• family history,
• emergency contact,
• consent,
• insurance or ID information.

Learner action: identify the time frame of each question. “Have you ever?” and “Are you currently?” are different.

症状: current symptoms

症状

means symptoms.

Common form questions:

どのような症状がありますか。 What symptoms do you have?

いつから症状がありますか。 Since when have you had symptoms?

症状の程度 severity of symptoms

Common symptom words:

発熱 fever

頭痛 headache

咳 cough

腹痛 abdominal pain

吐き気 nausea

Learner action: patient-friendly phrases may differ from form terms. 頭が痛い corresponds to 頭痛.

既往歴 and 家族歴

既往歴

means past medical history.

Examples:

これまでに大きな病気をしたことがありますか。 Have you had any major illnesses before?

手術歴 surgical history

入院歴 hospitalization history

家族歴

means family history.

It may ask whether family members have had particular conditions.

Learner action: 既往歴 concerns the patient’s past conditions; 家族歴 concerns relatives.

アレルギー

アレルギー

means allergy.

Forms may ask about:

薬のアレルギー medication allergies

食物アレルギー food allergies

造影剤アレルギー contrast-agent allergy

This is high-priority information. If unsure how to explain, ask for help rather than guessing.

服薬中

服薬中

means currently taking medication.

Related:

服用中の薬 medicines currently being taken

お薬手帳 medication notebook

サプリメント supplements

A form may ask you to list medication names and doses. If the medicine name is foreign or hard to write, showing the package or medication list may help.

妊娠

妊娠

means pregnancy.

Forms may ask:

妊娠中ですか。 Are you pregnant?

妊娠の可能性はありますか。 Is there a possibility of pregnancy?

This may affect testing, imaging, medication, and treatment. Do not ignore the difference between current pregnancy and possibility.

同意 and 署名

同意

means consent/agreement.

署名

means signature.

Examples:

検査に同意します。 I consent to the examination/test.

個人情報の取扱いに同意します。 I consent to the handling of personal information.

A signature may indicate consent, receipt of explanation, or confirmation of information. Read the sentence above the signature line.

緊急連絡先

緊急連絡先

means emergency contact.

Related fields:

氏名 name

続柄 relationship

電話番号 phone number

Learner action: 続柄 is often used in forms to ask relationship to the patient, such as spouse, parent, child, friend.

Example bank walkthrough

問診票

Medical intake questionnaire.

Learner action: form categories guide clinical conversation.

既往歴

Past medical history.

Learner action: patient’s previous illnesses/surgeries.

アレルギー

Allergy.

Learner action: high-priority safety information.

同意

Consent.

Learner action: read before signing.

症状

Symptoms.

Learner action: current condition category.

服薬中

Currently taking medication.

Learner action: list medicines accurately.

妊娠

Pregnancy.

Learner action: current or possible pregnancy may matter.

家族歴

Family medical history.

Learner action: relatives’ conditions.

署名

Signature.

Learner action: check what signature confirms.

緊急連絡先

Emergency contact.

Learner action: include reachable person and relationship.

Medical-form checklist

When filling a medical form:

1. Identify patient identity fields.
2. Mark current symptoms and onset date.
3. Separate current condition from past history.
4. List allergies carefully.
5. List current medications.
6. Answer pregnancy questions if relevant.
7. Read consent text before signing.
8. Fill emergency contact and relationship.
9. Ask staff if a question is unclear.
10. Do not guess on high-risk medical information.

Time-frame distinction on forms

Medical forms often ask about different time frames.

A wrong time frame can produce wrong clinical assumptions. 既往歴 is not current symptoms. 服薬中 is not medicines taken years ago.

Signature risk

A 署名 line may confirm different things:

• consent to treatment/test,
• confirmation that explanation was received,
• agreement to privacy handling,
• financial responsibility,
• accuracy of information.

Do not sign based only on seeing your name field. Read the sentence directly above the signature line.

High-priority fields

If language ability is limited, prioritize accuracy for:

1. allergies,
2. current medications,
3. pregnancy possibility,
4. current symptoms and onset,
5. serious past conditions,
6. emergency contact.

These affect safety more directly than many administrative fields.

A strong tool for this article would label form fields and risk terms.

Suggested functions:

1. Field labels: 症状, 既往歴, アレルギー, 服薬中, 妊娠.
2. Time-frame detector: current, past, family history.
3. Consent highlighter.
4. Signature warning.
5. Patient-friendly paraphrase.
6. Emergency-contact guide.
7. Medical safety reminder.

Final rule

Medical intake Japanese is ordinary language with high stakes.

問診票, 既往歴, アレルギー, 服薬中, 妊娠, 同意, 署名, and 緊急連絡先 are not vocabulary trivia. They structure care.

When unsure, ask. In medical settings, precision beats pride.