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Ageo Mental Clinic – Intake Questionnaire
Date of completion: 20____ / ____ / ____
1) Personal Information
Furigana (Phonetic) ————————————————————————————————————————————————————————————
Full Name ————————————————————————————————————————————————————————————
Sex (Male / Female) ————————————————————————————————————————————————————————————
Date of Birth (Era or Gregorian): (Year) (Month) (Day) ————————————————————————————————————————————————————————————
Age (years) ————————————————————————————————————————————————————————————
Address Postal Code: (____-____) ————————————————————————————————————————————————————————————
Contact phone number (reachable by the clinic) ————————————————————————————————————————————————————————————
Email Address ————————————————————————————————————————————————————————————
Have you informed your family/friends about today’s visit?
□ Yes ( ______________________ ) □ No
2) Companion(s) Today
Name ————————————————————————————————————————————————————————————
Relationship ————————————————————————————————————————————————————————————
3) How did you learn about our clinic? (Check all that apply)
□ Referral (from ______________________) □ Internet □ Flyer □ Signboard □ Recommendation by acquaintance □ Other ( ______________________ )
4) Whose wish was it to come today?
□ My own decision □ Recommended by family □ Recommended by workplace □ Other ( ______________________ )
5) Main Concern Today
Since when? ————————————————————————————————————————————————————————————
What exactly is the problem? (Please describe) ————————————————————————————————————————————————————————————
Possible triggers or life changes related to this problem ————————————————————————————————————————————————————————————
6) Past Psychosomatic/Psychiatric Care □Yes □ No
Period (from when to when) ————————————————————————————————————————————————————————————
Where (hospital/clinic name, etc.) ————————————————————————————————————————————————————————————
Diagnoses or symptoms ————————————————————————————————————————————————————————————
Treatments received (e.g., medication, counseling, hospitalization) ————————————————————————————————————————————————————————————
7) Past Medical History
If applicable, please check any conditions under treatment:
□ Diabetes □ Thyroid disease □ Glaucoma □ Benign prostatic hyperplasia □ Asthma □ Hypertension □ Heart disease □ Arrhythmia □ Liver disease □ Kidney disease □ Epilepsy □ Other ( ______________________ )
□ Currently receiving treatment – Facility/Department: ______________________
8) Current Medications/Supplements/Topical Agents □ Yes □ No
Details ————————————————————————————————————————————————————————————
9) Allergies (foods/medications) □ Yes □ No
Details ————————————————————————————————————————————————————————————
10) Background / Developmental History
Place of birth ————————————————————————————————————————————————————————————
Religion/faith: □ Yes ( ______________________ ) □ No
Final education (Graduated / Withdrew) Academic performance (e.g., above average): ————————————————————————————————————————————————————————————
Marital history: ( Single / Married / Divorced / Separated / Widowed )
Number of children: ( ____ )
With whom do you live? ————————————————————————————————————————————————————————————
11) Occupational History
Current job description ————————————————————————————————————————————————————————————
Years in current position ————————————————————————————————————————————————————————————
Main source of livelihood / income ————————————————————————————————————————————————————————————
Please list prior jobs (type of work and duration). If many, focus on recent years:
12) Original personality traits (circle/check all that apply)
Sociable, Prefer being alone, Gentle, Quiet, Active, Taciturn, Talkative, Patient, Short-tempered, Meticulous, Fastidious, Single-minded, Stubborn, Serious, Rough, Careless, Optimistic, Worrier, Caring, Unreliable, Emotionally labile, Competitive, Timid, Exaggerated, Modest, Easily influenced by others, Prone to daydreaming, Other ( __________ )
13) Family Information
Please fill in as much as you know. Indicate Health / Illness / Deceased (with cause).
| Family Member |
Age |
Occupation (or school year) |
Health status (Health / Illness / Deceased [cause]) |
| Father |
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| Mother |
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| Grandfather |
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| Grandmother |
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| Grandfather |
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| Grandmother |
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| Sibling |
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| Sibling |
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| Sibling |
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| Sibling |
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| Spouse |
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| Child |
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| Child |
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| Child |
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If the table above is insufficient, please add details here ——————————————————————————————————————————————————
Any blood relatives who have consulted psychosomatic medicine or psychiatry?
□ Yes ( Who? __________ For what? ______________________ ) □ No □ Unknown
14) Health & Lifestyle
- Height _____ cm, Weight _____ kg, Weight change: ( _____ months, _____ kg Increase / Decrease / No change )
- Alcohol: □ Drink ( Type: ______ / Days per week: _____ / Amount: ______ ) □ Do not drink
- Tobacco: □ Smoke ( _____ per day ) □ Do not smoke | Dominant hand: □ Right □ Left
- Coffee/Tea: □ Drink ( _____ cups per day ) □ Do not drink
- Any history of using narcotics/stimulants/cannabis/ecstasy/thinner/others? □ ( ______________________ ) □ None
- Sleep: □ Sufficient □ Insufficient □ Excessive Hours: ( ____ : ____ to ____ : ____ )
□ Difficulty falling asleep □ Awakenings during sleep □ Early morning awakening □ Unrefreshed sleep
- Appetite: □ Good □ Poor □ Fluctuating
- Bowel movements: □ Normal □ Diarrhea □ Constipation □ Alternating diarrhea & constipation
- Sexual desire: □ No change □ Decreased □ Increased
For women
- Menstruation: □ Regular □ Irregular □ Menopause
- Possibility of pregnancy: □ Yes □ No
- Breastfeeding: □ Yes □ No
15) Treatment Preferences / Requests
□ I would like a careful and thorough interview at the first visit.
□ I would like detailed explanations about my condition and treatment.
□ I prefer the visits (initial and follow-ups) to be as short as possible to reduce burden.
□ I am open to using prescribed medications for treatment.
□ I can take medicine, but I cannot take powders, very bitter medicines, or large capsules.
□ I prefer to minimize the use of prescribed medications.
□ I do not wish to take medications and prefer counseling only.
Other requests / Goals for treatment (please describe) ——————————————————————————————————————————————————
Thank you for your cooperation.
