General Care Intake Forms

Printable Intake Forms

Intake forms

These forms come directly from the Ministry of Health, Labour, and Welfare. Even if your clinic insists on you using their proprietary form, you can still print out a form from the list below and use it as a reference guide.

All of the forms are bilingual in Japanese and English, Chinese, Portuguese, or Spanish. Unfortunately, the MHLW does not provide these forms in any other languages at this time.

Please select the type of doctor you are planning to visit from the list below and print the form you need.

Cardiology (heart)

Cardiology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056967.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056968.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056970.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056971.pdf

Dentistry

Dentistry

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057033.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057034.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057035.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057036.pdf

Dermatology (skin)

Dermatology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056976.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056977.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056978.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056979.pdf

Gastroenterology (digestive)

Gastroenterology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056972.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056973.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056974.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056975.pdf

Internal Medicine

Internal medicine

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056955.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059937.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056961.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056962.pdf

Obstetrics and Gynecology (maternity & female reproductive system)

Gynecology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057028.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057029.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057031.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057032.pdf

Ophthalmology (eyes)

Ophthalmology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057018.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057020.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057021.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057022.pdf

Orthopedics (musculoskeletal)

Orthopedics

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057014.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057015.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057016.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057017.pdf

Otorhinolaryngology (ENT)

ENT

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057024.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057025.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057026.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057027.pdf

Pediatrics (children under 15)

Pediatrics

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059958.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059959.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059960.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059961.pdf

Psychiatry (mental health)

Psychiatry

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056984.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056985.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056986.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056987.pdf

Pulmonology (lungs)

Pulmonology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056963.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056964.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056965.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056966.pdf

Urology (urinary)

Urology

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057004.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057005.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057006.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057007.pdf

Surgery Intake Forms

Cardiac Surgery (heart surgery)

Cardiac surgery

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056998.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056999.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057002.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057001.pdf

General Surgery

General surgery

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056988.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056990.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000056993.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059962.pdf

Neurosurgery (brain surgery)

Neurosurgery

Japanese/English: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057008.pdf

日语・中文: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059939.pdf

Japonês / Português: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000057023.pdf

Japonés / Español: http://www.mhlw.go.jp/file/06-Seisakujouhou-10800000-Iseikyoku/0000059940.pdf