Name

Sex

Male

Female

I don't want to answer

Other

Tel/Cell

Date of birth 年月日

Postal code

Address

Prefecture and Municipalities

Address (building)

Occupation

If you selected "Google Search," what keywords did you use? (ex. Shiurayasu, Back Pain)

If you selected "Referral," please provide the name of the person who referred you.

Workplace （School）

For those who play sports
【Type of sport】

【Frequency】

【Team name】

Q2: When did the injury occur?

Q3: Please provide the suspected cause of your pain or injury.
Please answer as thoroughly as possible. This information is required for insurance claims. In some cases, the treatment may not be covered by insurance.

Q3-1: Where did the injury occur?

At home

Outside

On the field

その他（自由記述）

Q3-2: What were you doing when you got injured?

Sports

Housework

その他（自由記述）

Q3-3: How exactly did the injury occur?

Twisted

Hit something

Overstretched

その他（自由記述）

Q4: What movements cause the pain?

Q5: Have you already visited a medical facility for your current pain?

Yes

Q5-1: If you answered "Yes" above, please provide the name of the hospital or clinic.

Q5-2: If you answered "Yes" above, please provide the diagnosis or the names of any tests performed.

Q6: Have you ever had any major illnesses or injuries in the past?

Yes

Q6-1: If you answered "Yes" above, please provide the name of the illness or injury.

Q7: If it is determined that Non-insurance-covered treatment is necessary, would you like to proceed with treatment?

Depending on symptoms

Insurance-covered treatments only

Q7-1: Do you have any specific preferences for Non-insurance-covered treatment?

Acupuncture

Extended massage

Pelvic correction

Staff recommendation

None

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ケアクルにおける個人情報の取り扱いについては、プライバシーポリシーをご確認ください。

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