Talking to a Japanese Clinic: Intake Form and Phrase Cards
A bilingual intake sheet to fill in before you go, show-this phrase cards for reception and the pharmacy, and how to arrange an interpreter.
CommunicationThe short answer
On a first visit, reception usually hands you a *medical questionnaire (問診票, monshinhyō)* to fill in before you see the doctor. At many small clinics it is in Japanese only. Filling in the bilingual sheet below before you go, and showing the phrase cards at the counter, solves much of the language problem. Ask for professional language assistance when the conversation affects consent, medicine instructions or another medical decision.
This page helps you communicate. It does not interpret symptoms. Write down what you noticed in your own words and let the clinician decide what it means.
MonshinhyōOfficial multilingual questionnaires
Two free official sets already exist:
MHLW multilingual materials: questionnaires and explanation forms for medical institutions, with English and Japanese versions. MHLW: multilingual medical forms
Multilingual medical questionnaire (多言語医療問診票): questionnaires for 11 departments in 23 languages, free to download as PDFs, from the Kanagawa International Foundation and International Community Hearty Konandai. Multilingual medical questionnaire
Larger hospitals that accept foreign patients often keep their own translated forms. Ask at reception: 英語の問診票はありますか？ (Eigo no monshinhyō wa arimasu ka?, "Do you have an English questionnaire?")
If a box is unclear, ask staff. Do not invent a date, medicine name or history to finish the page. Show the original medicine label or record when you have it.
Fill in before you goBilingual intake sheet
Print this or copy it into your phone. Fill in the English side; staff read the Japanese column.
English
Japanese
Your answer
Full name (as on passport)
氏名
Date of birth
生年月日
Age and sex
年齢・性別
Nationality
国籍
Address in Japan (a hotel is fine)
日本での住所（ホテル可）
Mobile phone number
電話番号
Language you speak
話せる言語
Emergency contact (name and phone)
緊急連絡先（氏名・電話）
Japanese public health insurance
日本の健康保険
Yes 有 / No 無
Travel or private insurance (insurer and policy number)
旅行保険・民間保険（保険会社名・証券番号）
How you will pay
支払い方法
Cash 現金 / Card カード
What you want to discuss today
今日相談したいこと
When it started
いつからですか
Medicines you take regularly (name and dose)
常用薬（名前・量）
Medicines already taken for this
すでに飲んだ薬
Allergies (medicines, food, other)
アレルギー（薬・食物・その他）
None なし / Yes:
Past illnesses, operations or hospital stays
過去の病気・手術・入院
Pregnant or possibly pregnant
妊娠中・妊娠の可能性
No / Yes / Not sure
Breastfeeding
授乳中
No / Yes
Japanese questionnaires always ask about allergies, especially to medicines. If you have one, write the medicine name in English and show an allergy card or a photo of the label.
Bring your passport (visitors) or residence card and proof of Japanese health insurance (residents), a list or photos of your medicines, and your travel insurance details.
Show thisPhrase cards
Each line works on its own: show the Japanese to the person in front of you. The romaji is there if you want to say it.
At reception
You want to say
Show this
Romaji
I do not speak Japanese.
日本語が話せません。
Nihongo ga hanasemasen.
I have an appointment at (time).
（ ）時に予約があります。
(...) ji ni yoyaku ga arimasu.
I do not have an appointment. Can I be seen today?
予約はありません。今日診てもらえますか？
Yoyaku wa arimasen. Kyō mite moraemasu ka?
This is my first visit.
初診です。
Shoshin desu.
I do not have Japanese health insurance.
日本の健康保険に入っていません。
Nihon no kenkō hoken ni haitte imasen.
I filled in the questionnaire in English.
英語で問診票を書きました。
Eigo de monshinhyō o kakimashita.
Can I have an interpreter?
通訳をお願いできますか？
Tsūyaku o onegai dekimasu ka?
How long is the wait?
どのくらい待ちますか？
Dono kurai machimasu ka?
I need documents for my travel insurance.
旅行保険の請求のために書類が必要です。
Ryokō hoken no seikyū no tame ni shorui ga hitsuyō desu.
Please give me the receipt and the itemised statement.
領収書と診療明細書をください。
Ryōshūsho to shinryō meisaisho o kudasai.
Can I pay by card?
カードで払えますか？
Kādo de haraemasu ka?
Telling staff what you noticed
You want to say
Show this
Romaji
It hurts here.
ここが痛いです。
Koko ga itai desu.
I have a fever.
熱があります。
Netsu ga arimasu.
I have a cough. My throat hurts.
咳が出ます。喉が痛いです。
Seki ga demasu. Nodo ga itai desu.
I feel sick. I vomited.
吐き気がします。吐きました。
Hakike ga shimasu. Hakimashita.
I feel dizzy.
めまいがします。
Memai ga shimasu.
It started (today / yesterday / 3 days ago).
（今日／昨日／3日前）からです。
(Kyō / kinō / mikka mae) kara desu.
I am allergic to (penicillin).
（ペニシリン）にアレルギーがあります。
(Penishirin) ni arerugī ga arimasu.
I take this medicine every day.
この薬を毎日飲んでいます。
Kono kusuri o mainichi nonde imasu.
I am pregnant.
妊娠しています。
Ninshin shite imasu.
Could you explain that in plain language?
わかりやすく説明してもらえますか？
Wakariyasuku setsumei shite moraemasu ka?
Could you write that down?
書いてもらえますか？
Kaite moraemasu ka?
At the pharmacy
You want to say
Show this
Romaji
I have a prescription.
処方箋を持ってきました。
Shohōsen o motte kimashita.
Please explain how to take this medicine.
この薬の飲み方を教えてください。
Kono kusuri no nomikata o oshiete kudasai.
How many times a day? Before or after meals?
1日何回ですか？食前ですか、食後ですか？
Ichinichi nankai desu ka? Shokuzen desu ka, shokugo desu ka?
Ask whether the facility provides an interpreter or lets an outside interpreter join by phone or video. Confirm who supplies the device, whether booking is necessary and how private information will be handled. JIHS Center Hospital's own page gives an example of institutional language services. Availability elsewhere must be checked independently. Hospital language-support example
An automated translation can help with an address or a simple enquiry. Ask staff how they want to handle medical explanations, consent and uncertainty. Before leaving, ask about the follow-up process and any written instructions you do not understand.
CommunityWhat people online say
A visitor's Kyoto account described staff using a translation device and receiving an English medicine leaflet. The exact posting date was not clearly available in the retrieved page. These details are one person's experience, not proof that a particular device or English document will be available to you. We do not repeat the post's clinical advice or prices.
Official sources accessed 24 October 2026. The phrase cards are Care Compass Japan's own polite-form renderings for showing to staff, not a substitute for professional interpreting. Community material is not evidence of law, clinical suitability, prices or waiting times. This is navigation information, not a clinical review.
Information provided for planning purposes only. No diagnosis, treatment recommendations, or direct booking services.
YOUR NEXT STEP
Take this to your appointment.
Find a clinic in your language, or arrange an interpreter if the clinic has none.