Tf-clinic.jp

Patient Name Date of Birth / Age / Address Occupation（ ） Introduced by Internet・Newspaper・Magazine・TV・Radio □Stuck or uncomfort in Pharynx to chest □Heartburn □Reflux Esophagitis □Gastric Pain □Uncomfort and fullness of stomach □Sickness, Vomit □Worry for Helicobacter Pylori □Gastric Polyp □Gastric / Duodenal ulcer □Worry for Esophageal / Gastric Cancer □Blood in stool □Positive in Fecal occult blood test □Constipation □Diarrhea □Abdominal pain □Fullness of abdomen □Polyp in Colon □Worry of colon cancer If you have any other symptoms you are suffering, please state in below Please mark the box for examination which you request（All examinations will finish without any hospital stays. All examination will be charged as private practice □Same day examination＝ Having both “Upper GI Endoscopy” and “Colonoscopy” as below on the same day □High quality image Upper GI Endoscopy examination  Using NBI(Narrow Band Imaging) for pharynx, esophageal, gastric cancer examination screening  Helicobacter Pylori(Cause of gastric cancer) infection check  Perfect infection control= Using single use device for biopsy, send out for pathology □High-Vision Magnifying Colonoscopy examination  Using NBI to detect flat and depressed type cancer  Using High-Vision endoscope to achieve accurate diagnosis from high quality and resolution image  Using magnifying endoscope(up to ×100) to achieve accurate diagnosis the malignancy of the polyp  Complete from diagnosis to therapy including endoscopic surgery in single endoscopy  Resect all polyp and early stage cancer detected (Defined as “Clean colon”)  Ulcer surface after polyp resection will be fully closed. Ulcer surface after polyp resection(Over 20mm) will be closed using an ”8-Ring” device, designed and held patent by the director himself  Perfect infection control= Using single use device used in all endoscopic surgery Other Examinations（Will be additionally charged. Able to receive on the same day with endoscopy） □Blood examination；Cancer screening by tumor marker （Gastric, Colon, Lung, Breast, Liver, Ovary, Prostate cancer etc） □Ultra Sonic Cancer Screening；Thyroid、Abdomen（Liver・Gallbladder, Spleen, Kidney, Pancreas）、Prostate □Arterial Check；Measure “Arterial Age” by machine to medicine hyperlipemia, pre check for heart, brain disease □Carotid Ultra Sonic；Checking the risk of carotid vein hardening and stage □Cardiogram；Detecting Irregular Pulse, Angina, Infarction □Helicobacter Pylori Screening by Breath；Detect Helicobacter Pylori without endoscopy Other examination by coordinate hospitals（Introducing other hospitals） Screenings will be done by MRI, CT without any pain □Cancer Screenings for male patients；Lung, Prostate, Liver・Gallbladder, Pancreas Cancer Screening □Cancer Screenings for female patients；Breast, Uterus, Ovary Cancer Screening □Hear Examination；Examination for detecting angina and infarction □Brain Examination；Examination for detecting brain tumor, cerebral infarction, cerebral aneurysm Please fill below for patients wishing Upper GI Endoscopy ●Drinking and Smoking is related to the cause of Esophageal Cancer（Please mark circle on the numbers） １．Drinking habit I drink alcohol （ １．I don’t ２．More than once a week ３．Almost every night ） ※Do you turn red right after drinking？ Yes ・ No ２．Smoking habit I smoke （ １．I don’t ２．I used to but quitted ３．Yes I do smoke ） ※If you marked 2 or 3 to the question 2 above, please answer the period and amount in below Period of smoking（ From years old to years old, About cigarette a day ） ●Helicobacter Pylori is related to the cause of Gastric Cancer. １．Is this your first time having a Upper GI Endoscopy? Yes ・ No（ times including this time） ２．Is this your first time having a Helicobacter Pyloric screening？ Yes ・No（ times including this time） ３．Please answer the following for those the Helicobacter Pyloric screening result had been positive. （ Decolonized ・ Haven’t yet decolonized ・ I am not sure ） ※Please answer the following for those who have decolonized. When？ （about the age of ）, The decolonization was（Successful・Failed・I am not sure） Please fill below for patients wishing Colonoscopy. ●Polyps in the colon are related to colon cancer. １．Is this your first time colonoscopy? Yes ・ No（ times including this time） ２．Have you ever been detected colon polyps？ Yes ・ No ３．Do you no how many polyps have been detected? （ １～２ ・ ３～５ ・ more than ６ ・ I don’t know ） ●Are you taking any anticoagulant medicines？（ Yes ・ No ・ I don’t know ） Bufferin・Panaldine・Warfarin・Bayaspirin・Epadel・Persantin Opalmon・Anplag・Pletal Others（ ） Please state all medicines which you are taking today ●Have you ever felt sick during anesthesia in dental treatment or endoscopy examination? ●Are you allergic to any medicines （ Yes ・ No ・ I am not sure ） ●Please circle the following diseases which you have or had. High Blood Pressure・Low Blood Pressure・Angina・Myocardial Infarction・Irregular Pulse・ Cerebral Infarction・Prostatic Hypertrophy・Glaucoma・Hepatitis・Diabetes・Asthma ●If you have any diseases in current treatment please state below. ●Have you ever been gone under surgery? （ Yes ・ No ） Or, have you ever been diagnosed to any cancer? （ Yes ・ No ） Name of Disease： At the age of： Hospital Name： Actual treatment： ●Please state if your relatives has been diagnosed as cancer Thank you for your cooperation. Please hand this form to the reception after you’ve filled this form

Source: http://www.tf-clinic.jp/eng/pdf/ask.pdf