Pre-Visit Health Questionnaire

Thank you for choosing TRAIN clinic.

This questionnaire is designed to help us understand your condition before your appointment.

At TRAIN clinic, we do not only focus on the area where you feel pain or discomfort. We also consider your overall condition, including muscle tension, sleep, fatigue, digestion, stress, lifestyle, and other factors.

By completing this questionnaire in advance, we can better understand your condition and prepare a treatment plan that is more suitable for you.

Completing this questionnaire is optional.

However, we especially recommend it if you would like us to look at your whole body, combine acupuncture and massage, or provide treatment based on your overall condition.

This questionnaire may be helpful if you:

Have several symptoms or areas of discomfort
Would like acupuncture and massage
Would like us to assess your whole-body balance
Have ongoing or recurring symptoms
Have medical conditions or previous injuries that may be relevant
Find it difficult to explain your symptoms in English or Japanese during your appointment
Would like us to understand your condition before you arrive

Before You Start

Please answer only what you are comfortable sharing.

Most questions are optional.

The information you provide will be used only to help us understand your condition, prepare for your treatment, provide appropriate care, and contact you when necessary.

This questionnaire does not replace a medical examination or diagnosis.

If you have severe, sudden, or concerning symptoms, please seek appropriate medical care.

Health Questionnaire

Please complete the form below before your appointment.

Help us understand your body before your treatment.

At TRAIN clinic, we do not only focus on the area where you feel pain.
We also consider your overall condition, including muscle tension, sleep,
fatigue, digestion, stress, and other factors.

Completing this questionnaire before your visit helps us understand your
condition and prepare a treatment plan that better suits you.

This questionnaire is optional, but we recommend completing it if you would
like a more personalized acupuncture and massage treatment.

Basic Information

Name Required

Age Required

Gender

MaleFemaleOtherPrefer not to say

Email Address Required

Country / Region

Preferred Language

What Would You Like Help With?

Please describe your main concern or symptoms
Required

When did your symptoms begin?

Do you know what may have caused or triggered the problem?

What makes your symptoms worse?

Your General Health

These questions help us understand your overall condition and may be useful
when planning acupuncture treatment.

Stress and Daily Life

Please tell us anything about your work, lifestyle, exercise, sleep,
travel, or stress that may be related to your condition.

For Female Patients

Please provide any additional information if relevant.

Medical History

Have you seen a doctor for your current symptoms?

NoYesI plan to see a doctorNot sure

If yes, please tell us when and what type of doctor or clinic you visited.

Please tell us about any tests, diagnosis, or explanation given by your doctor.

Please tell us about any medical conditions, major illnesses,
injuries, or surgeries you have had.

Are you currently taking any medications?

Do you take blood-thinning medication?

NoYesNot sure

Do you have any allergies?

Acupuncture and Massage

Have you received acupuncture before?

YesNo

How do you feel about acupuncture?

I am comfortable with acupunctureThis is my first timeI am a little nervousI am afraid of needlesI prefer fewer needlesI prefer gentle acupunctureNo particular preference

Have you received massage or manual therapy before?

YesNo

Your Thoughts and Treatment Preferences

What do you think may be causing or contributing to your condition?

What would make today's treatment successful for you?

Do you have any requests or concerns about your treatment?

I prefer gentle treatmentI prefer stronger treatmentI am nervous about acupunctureI would like detailed explanationsI prefer to relax quietlyI would like acupuncture and massageI prefer mainly massageNo particular requestOther

Is there anything else you would like us to know before your visit?

Privacy

The information you provide will only be used to understand your condition,
prepare for your treatment, provide appropriate care, and contact you when necessary.
Your information will not be shared with third parties without your permission,
except where required by law.