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General Care Intake Forms

Printable Intake Forms

glasses

Here you can download and print First Visit forms to take with you to the doctor.


These forms come directly from the Ministry of Health, Labour, and Welfare. Even if your clinic insists on you using their proprietary form, you can still print out a form from the list below and use it as a reference guide.

All of the forms are bilingual in Japanese and English, Chinese, Portuguese, or Spanish. Unfortunately, the MHLW does not provide these forms in any other languages at this time.

Please select the type of doctor you are planning to visit from the list below and print the form you need.


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Cardiology (heart)

Cardiology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056967.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056968.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056970.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056971.pdf


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Dentistry

dentisry

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057033.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057034.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057035.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057036.pdf


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Dermatology (skin)

dermatology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056976.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056977.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056978.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056979.pdf


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Gastroenterology (digestive)

gastroent

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056972.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056973.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056974.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056975.pdf


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Internal medicine

internalmed

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056955.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059937.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056961.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056962.pdf


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Obstetrics and Gynecology (maternity & female reproductive system)

gynecology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057028.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057029.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057031.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057032.pdf


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Ophthalmology (eyes)

ophthalmology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057018.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057020.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057021.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057022.pdf


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Orthopedics (musculoskeletal)

orthopedics

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057014.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057015.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057016.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057017.pdf


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Otorhinolaryngology (ENT)

ent

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057024.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057025.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057026.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057027.pdf


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Pediatrics (children under 15)

pediatrics

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059958.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059959.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059960.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059961.pdf


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Psychiatry (mental health)

psychiatry

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056984.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056985.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056986.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056987.pdf


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Pulmonology (lungs)

pulmonology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056963.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056964.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056965.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056966.pdf


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Urology (urinary)

urinary

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057004.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057005.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057006.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057007.pdf


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Surgery Intake Forms

Cardiac Surgery (heart surgery)

cardiacsurgery

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056998.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056999.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057002.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057001.pdf


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General Surgery

generalsurgery

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056988.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056990.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056993.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059962.pdf


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Neurosurgery (brain surgery)

brain

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057008.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059939.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057023.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059940.pdf


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