How to Fill Out the Yokohama City Breast Cancer Screening Form
2025.10.18
How to Fill Out the Yokohama City Breast Cancer Screening Form
Full View of the Form
This is the entire form you will be filling out. The steps below explain how to fill in each section.
Step 1: Personal Information
Please fill in your personal details in the top section of the form.
- お名前(Name)
姓・名の順でご記入ください。(Please write your family name, then given name.)
- フリガナ(Furigana)
カタカナで名前の読み方を書きます。(Write the pronunciation of your name in Katakana.)
- 生年月日(Date of Birth)
和暦（大正・昭和・平成）に◯をつけ、年月日を記入します。(Circle the era name and write your birth year, month, and day.)
- 年齢(Age)
- 住所(Address)
- 連絡先(Contact Number)
電話番号をご記入ください。(Your phone number.)
【記入箇所 / Area to fill】
Step 2: 問診Medical Questionnaire
【Area to fill】
。
Please answer the questions in the large central box. Circle the number that applies to you.
既往歴・家族歴
Medical & Family History
- 妊娠・分娩・身長・体重(Pregnancy, Deliveries, Height, Weight)
- 最近の月経・閉経(Most recent period / Menopause)
- 過去3年以内に横浜市乳がん検診を受けたか(Had Yokohama breast screening in last 3 years?)
- 3年以内にマンモグラフィを受けたか(Had a mammogram in the last 3 year?)
- ペースメーカー等の装着(Have a pacemaker, etc.?)
- 1.血縁者に「乳がん」の人がいるか(4. Blood relatives with breast cancer?）
- 2. 乳房の病気にかかったことがあるか(2. Ever had other breast diseases?)
- 3. 乳房の手術や豊胸術を受けたか(3. Ever had breast surgery or augmentation?)
- 4. ホルモン治療を受けたことがあるか(4. Ever had hormone therapy?)
自覚症状
Current Symptoms
- 5. 乳房にいたみがあるか(5. Have pain in your breast?)
- 6. 乳房にくぼみ（ひきつれ）があるか(6. Have dimpling in your breast?)
- 7. 乳房にしこりがあるか(7. Have a lump on your breast?)
- 8. ちくびの陥没や変形があるか(8. Have an inverted nipple?)
- 9. ちくびからの分泌物があるか(9. Have nipple discharge?)
(About the Choices)
For most questions, you will have the following choices:
- 1. ない(1. No / I don’t have it)
- 2. ある(2. Yes / I have it) – もし「ある」場合、(右・左 / Right・Left) のどちらかもお答えください。(If yes, please also indicate Right or Left.)
