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診療申込書（English）
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- Past history of diseases?
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If you answered yes
What diseases : - Familiar history of special diseases?
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If you answered yes
Who :
What diseases : - Do you have any allergic reaction?
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If you answered yes
What medicine : - Present illness
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from when what part symptom past treatment - Do you want to blood examination of STD(sexual transmit diseases)?
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- How would you know this clinic?
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