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福岡市地下鉄 西新駅／藤崎駅 徒歩「高取商店街」の眼科
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  2. Online Medical Questionnaire (First Visit)

Online Medical Questionnaire (First Visit)

Takeru Eye Clinic – Online Medical Questionnaire (First Visit)

Takeru Eye Clinic
Online Medical Questionnaire (First Visit)

Please answer the following questions to help us provide you with the most accurate and efficient care.
Your personal information will be kept strictly confidential in accordance with medical regulations and will only be used for clinical purposes.

1. Purpose of Your Visit Today *

2. Use of Glasses / Contact Lenses *

3. Current Symptoms

Please check all that apply and select the affected eye (Right, Left, or Both).

4. When did these symptoms start?

5. Medical History, Past Surgeries, and Current Medications

Do you have any current or past major health problems?

6. Allergies

7. For Female Patients

8. Are you concerned about any eye diseases (even without symptoms)?

9. Please list any eye diseases your family members have.

10. If there is anything else you would like to tell us, please write it here.

How did you get here today?

How did you hear about our clinic? (Select all that apply)

If required fields are not filled in, you may not be able to submit. Please check your entries.

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