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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
Mother
Grandfather
Grandmother
Grandfather
Grandmother
Sibling
Sibling
Sibling
Sibling
Spouse
Child
Child
Child
(Additional)

 

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.