Questionnaire (for adults) / 問診票(大人用)
If possible for the first patient, please fill out the following questionnaire and send it. The response at the visit will be smooth. This is an adult questionnaire.

The questionnaire is an important reference material for your medical care. Your privacy will be strictly followed, so please fill in as accurately as possible.

* This questionnaire will be completed within 1 minute.

* Required



Email address *
Name / 名前 *
Your answer
Kana / ふりがな
Your answer
Sex / 性別 *
Age / 年齢 *
Your answer
What symptoms do you have? / どうなさいましたか
Please check the applicable items (multiple selections possible) / 当てはまるものにチェックをいれてください(複数選択可)
Tooth / 歯
Gums / 歯ぐき
Dentures / 入れ歯
Chin / あご
Other / その他
The reason for knowing our hospital is / 当院をお知りになった理由は *
If you have selected “Introduction from an acquaintance or family”, please fill in the name of the introducer. / 「知人・家族からの紹介」と選択した方は、差し支えなければご紹介者名をご記入ください。
Your answer
What was the last dental treatment you received? (Example: 2 years ago, 1 month ago) / 最後に歯科治療を受けられたのは?(例:2年前、1ヶ月前) *
Your answer
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