CONSULTATION SHEET
Name
Sex
Male
Female
Email
Tel/Cell
Date of birth
Postal code
Address
Occupation
Office worker
Student
Self-employed
Homemaker
Other
How did you hear about our clinic?
Referral
Google Search
Neighborhood
Flyer
Social Media
その他（自由記述）
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】
Q1: Please touch the area where you feel pain.
Q2: When did the injury occur?
Q2-1: When was the most recent time you felt pain?
1 week ago
2–4 days ago
Yesterday
Today
その他（自由記述）
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
No
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
No
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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