Inquiry Form
(for overseas patients)
Date:
(DD/MM/YYYY)
Patient Information
First name (required):
Date of birth (required):
Last name (required):
(DD/MM/YYYY)
Gender (required): □ Male □ Female
Nationality/Home country (required):
Home address (required):
Telephone number (required):
Mobile number:
Email address (required):
Native language (required):
Other language(s) you understand:
□ Japanese □ English □ Other(s)
Chief complaint(s) (required):
Other complaint(s):
Diagnosis (required):
Details of inquiry (required)
History of present illness (required):
Past medical history (required):
Reason(s) why you would like to be examined/receive treatment at the University of Tsukuba
Hospital
Department you would like to be examined/receive treatment at:
□ Cardiology □ Gastroenterology □ Pneumology □ Nephrology □ Neurology
□
□
□
□
□
□
Other internal medicine department(s):
Gastrointestinal surgery □ Cardiovascular surgery □ Neurosurgery □ Orthopedics
Other surgical department(s):
Pediatrics □ Obstetrics and gynecology □ Otorhinolaryngology (ENT) □ Ophthalmology
Dermatology
Other department(s):
Other request(s)
Information on the person who wrote this form, if different from the patient
First name (required):
Date of birth:
Last name (required):
(DD/MM/YYYY)
Gender: □ Male □ Female
Relation to the patient (required):
Nationality/Home country:
Home address:
Telephone number required):
Email address (required):
Native language (required):
Other language(s) you understand:
Mobile number:
□ Japanese □ English □ Other(s)