〒108-0075
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東京都港区港南２−１６−７品川Vタワー内１F
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tel.03-3474-5263
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痛くない治療
頭しらみ
アトピー性皮膚炎について
爪白癬（爪水虫）について
Name
Sex
M
F
Age
Nationality
Address
Zip Code
Phone＃
Health Insurance
Occupation/School
Past history of diseases
No
Yes：
When
What diseases
Familiar history of special diseases
No
Yes：
Who
What diseases
Do you have any allergic reaction?
No
Yes：
What foods
What medicine
Present illness
from when
what part
symptom
itchy
pain
past treatment
Do you want to blood examination of STD(sexual transmit diseases)?
AIDS
Syphilis
Herpes
*These examinations are occasionally not covered by your insurance.
How would you know this clinic?
Thank you.
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