How to Fill Out the Yokohama City Cervical Cancer Screening Form(for 20-29 / 61ｰ yrs old women)
How to Fill Out the Yokohama City Cervical Cancer Screening Form
A Guide for English Speakers
Navigating paperwork at a clinic in Japan can feel a little daunting, especially when everything is in Japanese. But don’t worry! If you’re going for a cervical cancer screening in Yokohama, we’ve got you covered.
This guide will walk you through exactly how to fill out the screening form, step by step.
Step 1: The Big Picture
First, let’s look at the entire form. It might seem like a lot, but the good news is you only need to fill out the sections inside the large, bold-lined box. The clinic staff will handle the rest.
You only need to write in the area inside the bold-lined box.
Step 2: Your Personal Information
Now, let’s zoom in on the top part. This is where you’ll write your personal details.
1. お名前 (O-namae): Name
Write your full name here.
2. 生年月日 (Sei-nen-gappi): Date of Birth
Write your date of birth. The format is often based on the Japanese era, but writing it in the Western format (Year/Month/Day) is usually fine.
3. 住所 (Juusho): Address
Write your current address in Yokohama.
4. 連絡先 (Renraku-saki): Contact Number
Write your phone number where the clinic can reach you.
Right below your contact info, you’ll see this question:
今日、いずれかの横浜市の健診・がん検診を受けましたか。
(Have you undergone any other Yokohama City health check-ups or cancer screenings today?)
Circle はい (Yes) or いいえ (No).
Step 3: The Medical Questionnaire (問診 – Monshin)
Finally, let’s tackle the questionnaire section at the bottom. Just circle the number that corresponds to your answer. `1` is for Yes (はい), and `2` is for No (いいえ).
1. 過去6ヶ月以内に不正出血（月経以外の出血や茶色いおりもの）がありましたか？
Have you had any abnormal bleeding (bleeding other than your period, or brown discharge) in the last 6 months?
2. 最近、月経に異常がありましたか？
Have you had any menstrual irregularities recently?
→→→上記1と2で「はい」の方は医師にご相談ください。
This is a note: If you answered “Yes” to questions 1 or 2, please consult with the doctor.
3. 子宮頸部の病気（がん疑い、異形成など）で、医療機関を定期的に受診していますか？
Are you regularly visiting a medical institution for a cervical condition (suspected cancer, dysplasia, etc.)?
4. 子宮体部の病気で、医療機関を定期的に受診したり治療を受けていますか？
Are you regularly visiting a medical institution or receiving treatment for an endometrial (uterine body) condition?
5-1. 子宮の手術を受けたことがありますか？ (Have you ever had uterine surgery?)
5-2「はい」の方へ: 「子宮頸部」は残っていますか？ (For those who answered “Yes”at 5-1: Do you still have your cervix?)
1: はい (Yes), 2: いいえ (No), 3: わからない (I don’t know)
→→→上記３，４で「はい」のかた、および５－２で２の方は検査対象外となります。
This is a note:If you answered ‘Yes’ to questions 3 or 4, or answered ‘2’ for question 5-2, you are not eligible for this examination.
6. 性交交渉の経験はありますか？
Have you ever had sexual intercourse?
→→→「いいえ」の方は子宮頸がんを罹るリスクは極めて低いと考えられますが、希望される方は検診を受けることができます。 If you answered “No” to question 7, your risk of developing cervical cancer is considered extremely low, but you can still choose to undergo the screening if you wish.
7.子宮頸がん予防ワクチンの接種を受けたことはありますか？（Have you ever had the HPV vaccine?）
8.（閉経していない方）最終月経を書いてください。月 日（If you are not menopausal, please provide the date of your last menstrual period）Month/date
9. 妊娠している方 (For those who are pregnant)
This question asks if you are pregnant and, if so, how many weeks along you are. If not pregnant, leave it blank.
妊娠 (Pregnancy): __ 週 (weeks)
