Tokyo Medical and Surgical Clinic

US VISA Application Form

Please enter all information in English.

Personal Details

**All information is kept strictly confidential.**

Personal Details

Surname*

Given Names*

Date of birth * Month Day Year Sex * Male Female

Case or Alien Number*

Birthplace (City, Country)*

E-mail Address*

Confirm E-mail Address*

Telephone Number*

Mobile Number*

Present Country of Residence*

Prior Country of Residence*

Present Address of Residence*

Present City of Residence*

Present Postal Code of Residence*

Intended US Address

Intended US City

Intended US State

Intended US Postal Code

Medical History

1. Medical History

General

Yes

Illness or injury requiring hospitalization (including psychiatric)

Cardiology

Yes

Hypertension

Yes

Congestive heart failure or coronary artery disease

Yes

Arrhythmia

Yes

Rheumatic heart disease

Yes

Congenital heart disease

Pulmonology

Yes

Tobacco use:

Current

Former

Yes

Asthma

Yes

Chronic obstructive pulmonary disease

Tuberculosis history

Diagnosed Month Year

Treated Month Year

Yes

Fever

Yes

Cough

Yes

Night sweats

Yes

Weight loss

Psychiatry

Yes

Psychological/Psychiatric Disorder (including major depression, bipolar disorder, or schizophrenia)

Yes

Major impairment in learning, intelligence, self-care, memory, or communication

Yes

Use of drugs other than those required for medical reasons

Yes

Substance use or substance induced disorders or substances on the Controlled Substances Act (CSA)

Yes

Other substance related disorders (including alcohol abuse or dependence)

Yes

Ever caused serious injury to others, caused major property damage or had trouble with the law because of medical condition,
mental disorder, or influence of alcohol or drugs

Yes

Ever had thoughts of harming yourself

Yes

Ever acted on those thoughts

Yes

Ever had thoughts of harming others

Yes

Ever acted on those thoughts

Neurology

Yes

History of stroke

Yes

Seizure disorder

Obstetrics

Yes

Pregnancy, current

Estimated delivery date (mm-dd-yyyy) Month Day Year

LMP Month Day Year

Previous live births, number

Birth dates of live births (mm-dd-yyyy)

1 Month Day Year

2 Month Day Year

3 Month Day Year

4 Month Day Year

5 Month Day Year

6 Month Day Year

Sexually Transmitted Diseases

Previous treatment for sexually transmitted diseases

Yes

Gonorrhea

specify date and treatment

Month Year

Yes

Syphilis

specify date and treatment

Month Year

Endocrinology

Yes

Diabetes mellitus

Yes

Thyroid disease

Hematologic/Lymphatic

Yes

Anemia

Yes

Sickle Cell Disease

Yes

Thalassemia

Yes

Other hemoglobinopathy

Other

Yes

An abnormal or reactive HIV blood test HIV

Diagnosed

Month Year

Yes

Malignancy

specify

Yes

Kidney or bladder disease

Yes

Chronic liver disease(including hepatitis B or C)

Yes

Previous treatment for Hansen’s Disease

Treatment Completed

Month Year

Yes

Other medical conditions requiring treatment

specify

Yes

Disabilities(including loss of arms or legs)

specify

Current Medications

2.Current Medications

3.Previous Surgeries・hospitalizations

3.Previous Surgeries・hospitalizations