How to Fill Out a Medical Exam Form at a Doctor’s Office in Japan: With Japanese-English Translation

When you visit a doctor’s office or hospital in Japan, you’ll be asked to be fill out a short medical questionnaire / examination form. In Japanese, this form is called a 問診票 (monshinhyou). Basically, this is the intake form where you provide basic information about yourself, your symptoms and a little about your medical history.

In this article, we provide English translations of the most commonly asked questions and words used in a typical medical questionnaire.

Some major hospitals in Tokyo, Osaka, and other big cities have English-speaking staff and English forms but most clinics and hospitals in smaller cities do not. In Tokyo, three well-known hospitals serving the English-speaking community are: Tokyo Takanawa Hospital Internatioal Clinic, St. Luke’s International Hospital, and Sanno Hospital.

There is no single standard Japanese medical questionnaire/exam form. Here is an example of a form you would fill out at an internal medicine clinic (where you would go, for example, if you have a cold or need a primary care physician).

Example of a medical questionnaire form used in Japan.

Below we give the Japanese kanji, romaji, and English translation of the most commonly asked questions and commonly used words.

General Information

Japanese Romaji English
氏名
Shimei Name
日付 Hizuki (Today’s) Date
生年月日 Seinengappi Birthdate
Nen Year
Tsuki Month
Hi Day
性別 Seibetsu Sex
Otoko Male
Onna Female
ご住所 Gojūsho Address
連絡先 Renraku saki Contact Info
自宅 Jitaku Home
携帯 Keitai Mobile
身長 Shinchō Height
体重 Taijū Weight
本日の温度 Honnichi no ondo Your body temperature (today)
現在通院中の病院などはありますか? Genzai tsūin-chū no byōin nado wa arimasu ka? Are you currently going to any other hospitals/clinics?

Symptoms

Not all questionnaire forms have a section asking you to check off your symptoms, but it’s still useful to know the main words to describe the most common ones.

Japanese Romaji English
症状 Shōjō Symptoms
どのような症状ですか? Dono yōna shōjō desu ka? What symptoms do you have?
それはいつからですか? Sore wa itsu kara desu ka? When did the symptoms start?
今日 Kyou Today
昨日 Kinou Yesterday
一週間前 Isshūkanmae One week ago
一ヶ月前 Ikkagetsumae One month ago
以上 Ijyou More than. As in “More than 1 month ago”
喉が痛い Nodo ga itai Sore throat
胸が痛い Mune ga itai Chest pain
吐き気 Hakike Nausea
下痢 Geri Diarrhea
血便 Ketsuben Bloody stool
高血圧 Kōketsuatsu High blood pressure
疲れやすい Tsukareyasui Easily fatigued
身体がふるえる Karada ga furueru Shaking / shivering
めまい Memai Dizziness
せき Seki Cough
胸が苦しい Mune ga kurushii Chest discomfort
嘔吐 Ōto Vomiting
お腹が張る Ohara ga haru Abdominal swelling
熱がある Netsu ga aru Fever
眠れない Nemurenai Can not sleep
体重が減っている Taijū ga hette iru Weight loss
勝手に動く Katte ni ugoku Involuntary (body) movements
口が渇く Kuchi ga kawaku Dry mouth
動悸 Dōki Palpitations
胃が痛い I ga itai Stomachache
お腹が痛い Onakagaitai Abdominal pain
息切れ Ikegire Shortness of breath
発疹 Hosshin Rash
だるい Darui Lack of energy
食欲がない Shokuyoku ga nai Loss of appetite
寒い Samui Coldness
全身にむくみがある Zenshin ni mukumi ga aru Swelling of the whole body
体にの部にむくみがある Karada no ichibu ni mukumi ga aru Swelling in part of the body
痺れ Shibire Numbness / tingling
その他 Sonota Other (Symptoms)

Medical History

These questions cover your medical history, including whether you’ve ever had a major illness, whether you’re allergic to anything and your smoking and drinking habits.

Japanese Romaji English
はい Hai Yes
いえ Ie No
現在治療している病気はありますか? Genzai chiryō shite iru byōki wa arimasu ka? Are you currently undergoing treatment for any illnesses?
病名 Byōmei Name of disease
薬や食べ物でアレルギーがでますか? Kusuri ya tabemono arerugī ga demasu ka? Are you allergic to any foods or medications?
Kusuri Medication
食べ物 Tabemono Food
その他 Sonota Other
現在飲んでいる薬はありますか? Genzai nonde iru kusuri wa arimasu ka? Are you currently taking any medications?
持っていれば見せてください Motte ireba misete kuta ゙ sai Please show us the medications if you have them with you.
今までにかかった病気はありますか? Ima made ni kakatta byōki wa arimasu ka? Have you previously had any of the diseases listed below?
胃腸の病気 Ichō no byōki Gastrointestinal disease
腎臓の病気 Jinzō no byōki Kidney disease
脳・神経系の病気 Nō shinkei-kei no byōki Brain and nervous system diseases
甲状腺の病気 Kōjōsen no byōki Thyroid disease
肝臓の病気 Kanzō no byōki Liver disease
呼吸器の病気 Kokyū-ki no byōki Respiratory disease
糖尿病 Tōnyō-byō Diabetes
心臓の病気 Shinzō no byōki Heart disease
血液の病気 Ketsueki no byōki Blood disease
Gan Cancer
たばこを吸いますか? Tabako o suimasu ka Do you smoke?
吸う Suu (Yes), I smoke.
現在 Genzai Currently. As is, “Cuurently, how much do you smoke?”
本/日 Hon / Hi # of Cigarettes Per Day
喫煙歴 Kitsuen-reki Duration (How long you smoked)
以前吸っていた Izen sutte ita No, but I used to smoke.
過去 Kako Previous (amount you used to smoke).
吸わない Suwanai No, I don’t smoke
お酒を飲みますか? Osake o nomimasuka? Do you drink alcohol?
手術を受けたことがありますか? Shujutsu o uketa koto ga arimasu ka? Have you ever had surgery
いつごろですか? Itsu goro desu ka? When (did you have surgery)?
手術名 Shujutsu-mei Type of surgery
麻酔を受けたことがありますか? Masui o uketa koto ga arimasu ka? Have you ever had anesthesia?
全身麻酔 Zenshin masui General anesthesia
局所麻酔 Kyokusho masui Local anesthesia
麻酔をして何かトラブルがありましたか? Masui o shite nanika toraburu ga arimashita ka? Did you have any problems related to the anesthesia?
妊娠していますか、またその可能性はありますか? Ninshin shite imasu ka, mata sono kanōsei wa arimasu ka? Are you pregnant or is it possible?
ヶ月 Ka getsu [Number] of months (pregnant)
わからない Wakaranai I do not know.
授乳中ですか? Junyū-chūte desu ka? Are you breastfeeding?

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