FormA
Attending Physician's Statement
診療内容明細書
1. Name of Patient (Last, First) Age (Date of Birth) Sex (MaIe・Female)
患者名 年齢(生年月日) 性別(男・女)
2. Name of Illness or lnjury preferably with Number of lnternational Ciassification
of diseases for the use National Health lnsurance (See the other side of this form)
傷病名及び国民健康保険用国際疾病分類番号(裏面参照)
3. Date of First Diagnosis: D / M /Y / /
初診日 日/月/年 / /
4. Duration of Treatment: days
診療日数 日
5. Type of Treatment
治療の分類
□HospltaIization:From / / , to / / ( days)
入院 自 / / 至 / / ( 日間)
□Out patient or Home Visit: / / / /
入院外 / /
/ /
6. Nature and Condition of Illness or lnjury (in brief)
症状の概要
7. Prescription, Operation and Any other treatments (in brief)
処方、手術その他の処置の概要
8. Was the treatment required as a result of an accidental injury? Yes□ No□
治療は事故の傷害によるものですか。 はい いいえ
9. Itemized Amounts paid to HospitaI and / or Attending Physician: formB
治療実費 様式B
10. Name and Address of Attending Physician
担当医の名前及び住所
Name名前: Last姓 First名 title称号
Address住所 :Home自宅 phone電話
Office病院又は診療所 phone電話
Date日付: Signature署名
AttendingPhysician担当医
Reference Number of your Medical Record (if applicable)
診療録の番号