問もん診しん票ひょう

noun

medical questionnaire; medical history form

A form filled out by patients before a medical consultation, covering symptoms, past illnesses, allergies, and lifestyle.

• 初しょ診しんの方かたは問もん診しん票ひょうにご記き入にゅうください。

  First-time patients, please fill out the medical questionnaire.

• 問もん診しん票ひょうをもとに医い師しが症しょう状じょうを聞ききます。

  The doctor will ask about your symptoms based on the medical history form.