Yuushin Internal Medicine Clinic

Medical Diet Questionnaire (Return Visit)

Please fill in all required fields. After submitting, please remain seated — a staff member will call you when ready.

Basic Information

Full NameRequired

Please enter your name in English (letters only), exactly as it appears on your passport.

Please enter your name in English letters, as shown on your passport.

GenderRequired

Male Female

Please select your gender.

Date of BirthRequired

Enter 8 digits in the order Year / Month / Day (slashes are added automatically).

Please enter a valid date (YYYY/MM/DD).

Age (calculated automatically)

Medication can only be prescribed to those aged 18 and over.

Body Information

HeightRequired

Please enter your height.

WeightRequired

Please enter your weight.

BMI (calculated automatically)

Medication cannot be prescribed to those with a BMI of 18.5 or below.

Requested Medication

Please enter the medication, dose, and quantity you would like.Required

Please enter the medication you would like.

Contraindications / Confirmation

Are you pregnant or breastfeeding, planning pregnancy within 3 months, or within 3 months after childbirth?Required

Yes No

Medication cannot be prescribed in this case.

Please select an option.

For patients who would like a detailed consultation with the doctor A medical diet consultation basically consists of reviewing the questionnaire and confirming your identity.
If you would like any of the consultations below, an additional consultation fee of ¥5,500 applies (consultation in English only).

How to use the injection
Which medication is right for me
Adjusting the dose or timing of administration
How to manage side effects

I would like a detailed consultation with the doctor (consultation fee ¥5,500, in English).If you do not purchase medication, an additional ¥11,000 applies.

✓

Your form has been submitted

Please remain seated.
A staff member will call you
when we are ready.

You do not need to use
the self-check-in machine.