Your answers on this form will help your doctor better understand your medical concerns and conditions. If you are uncomfortable with any question, do not answer it. We have designed these forms with accessibilty in mind.

Please answer the following questions about your eyes

右目 Right eye? no yes
左目 Left eye? no yes
涙 が出る - Do you have tearing? yes no
痛みがある - Is there any pain? no yes
目やにが出る - Is there any discharge? no yes
目の腫れ - Is your eye swollen? no yes
異物感がある - Something is in my eye no yes
ぼやける - Is your vision blurred? no yes
眩しい - Are you sesitive to light? no yes
目の遺伝病がある - A family have history of eye disease? no yes

視野欠損 - Has your field of vision change? no yes

最近人や物によくぶつかる - Have you been bumping into things? no yes


糖尿病がある - Are you diabetic? no yes

When you print this page only the necessary information will be printed. We have removed images and turned off colours.

hcard information Mark Holloway |
http://www.healthhokkaido.com
Sapporo, Hokkaido Japan
45.670074-111.037184
Dr. T. Oshimi
http://www.healthhokkaido.com
Sydney,  Australia
45.670074-111.037184
Chika Kitano
http://www.healthhokkaido.com
Sapporo, Hokkaido Japan
45.670074-111.037184

| health information for Japan's people | founded in 2006 | aim: accessible and informative |