Web Medical Questionnaire

Name

Date of birth: Year Month Day

Age: years old

Sex: Female Male

Post code: 〒

Address

Telephone number

Email address

Your profession

Weight (0.5kg increments): kg

Height (0.5cm increments): cm

At our clinic, we aim to provide natural rejuvenation and skin beautification treatment for people between the ages of 5 and 28.

Area of concern 1: ①Wrinkles between the eyebrows ②Sagging eyelids ③Wrinkles around the corners of the eyes ④Sagging cheeks ⑤Stains ⑥Nasolabial folds ⑦Acne ⑧Acne scars ⑨Marionette lines ⑩Face line sagging ⑪Wrinkles on the neck ⑫Wrinkles on the forehead ⑬Dents in the temples ⑭Wrinkles next to the nose ⑮Wrinkles and hollows around the eyes ⑯Sunken cheeks ⑰Enlarged pores (cheeks) ⑱Enlarged pores (nose) ⑲Facial slimming ⑳Lip rejuvenation and thickness ㉑Chin wrinkles/double chin

Do you have any concerns other than those listed above?: Stain Drying Red face Moles Warts Eyelash hair growth Hyperhidrosis Hair removal Thinning hair Body shape Others

When did you start to notice it?: year ago,

months ago,

Have you ever received treatment for the above concerns?: Yes No

How much rejuvenation do you want? *This question is related to the realm of natural rejuvenation.: Only you can feel it yourself People around you say that you look more youthful and lively Naturally rejuvenated looking back to 5 to 10 years old both to yourself and those around you

How much do you want your skin to be beautiful?: Only you can feel it yourself (bumpy pimples disappears etc.) People around you can see that your skin has become clearer (acne scars disappear

Are there any events coming up soon? *Parties, reunions, visiting days, girls' nights out, family gatherings: A few weeks later Within 1 month Within 2 months 3 months or more No
*We will suggest the best treatment so that you can enjoy these event even more.

What do you see in others (classmates, celebrities, etc.) that you find youthful or beautiful? (Multiple selections possible): Glowing skin Firm skin Smooth skin without pores Lively complexion Transparent skin Youthful look Shiny hair with volume

Please check the treatment you are interested in (multiple selections possible): Regenerative medicine (PRP therapy/stem cell transplantation) Botox injection Hyaluronic acid injection Laser Photofacial Earrings Peeling Hair removal Fat dissolving injection Water light injection Beauty injection Oral medicine External medicine Cosmetics Bridal beauty esthetics HIFU laser Derma Pen

Do you currently have any illness or are undergoing treatment?: Yes No

Are you currently taking any medications?: Yes No

Have you ever had an allergy to medicine, food, or alcohol?: Yes No

Have you ever been diagnosed with anemia or low hemoglobin?: Yes No

Are you currently pregnant or potentially pregnant?: Yes No Prepare to become pregnant During reastfeeding

Are there any metal objects such as plates or bolts, gold thread, or silicone inserted into your body?: Yes No

Are there any scars or bruises on your body?: Yes No

Do you have any experience in receiving treatment at a beauty clinic?: Yes No

Do you have any tattoos on your body?: Yes No

Please tell us your skin type: Normal skin Sensitive skin(easily red) Oily skin Dry skin Acne skin Easy to get a rash Atopic dermatitis Prone to eczema Easy to get sunburned Turns red when exposed to the sun Keloid constitution

Please tell us about the triggers lead you came to our clinic.: Home page SNS (Twitter Instagram Facebook) LINE JR Hamamatsucho Station signboard poster atre takeshiba poster City living Seagull leaflet Hotpepper

Please tell us about the skin you want and your ideal skin condition.

Would it be okay for our clinic to contact you via DM, etc.?: Yes No

About Four Seasons Cosmetic Dermatology Clinic

Tokyo Clinic

Address

〒105-0022
1-10-30 Kaigan, Minato-ku, Tokyo
Atre Takeshiba Tower Building 3FGoogle Map

Access

6 minutes walk from Hamamatsucho Station
3 minutes walk from Takeshiba Station

Telephone number

03-6803-4908

https://tokyo.four-seasons.jp/en

Business hours	Mon	Tue	Wed	Thu	Fri	Sat	Sun
10:00~20:00	◯	◯	◯	◯	◯	◯	◯
Business hours are the same even on holidays Please contact the clinic directly for business hours.

Four Seasons Cosmetic Dermatology Ginza (Counseling Room)

Address

〒104-0061
Okura Annex 5F, 3-4-1 Ginza, Chuo-ku, Tokyo
Google Map

Access

4 minutes walk from Tokyo Metro Ginza Line/Marunouchi Line/Hibiya Line 「Ginza Station」
5 minutes walk from Yurakucho Station on the JR/Tokyo Metro Yurakucho Line

Telephone number

03-6893-2926

Business hours	Mon	Tue	Wed	Thu	Fri	Sat	Sun
10:00~20:00	◯	◯	◯	◯	◯	◯	◯
Business hours are the same even on holidays Please contact the clinic directly for business hours.

Kobe central clinic

Address

〒650-0001
6-6-1 Kanocho, Chuo-ku, Kobe City, Hyogo Prefecturer
Kanazawa Sannomiya Building 8F
Google Map

Access

5 minutes walk from Sannomiya Line

Telephone number

078-321-1121

https://four-seasons.jp/

Business hours	Mon	Tue	Wed	Thu	Fri	Sat	Sun
10:00~20:00				◯	◯	◯	◯
10:00~22:00	◯	◯	◯
Business hours are the same even on holidays Please contact the clinic directly for business hours.

Kobe 2nd clinic

Address

〒650-0012
1-20-13 Kitanagasadori, Chuo-ku, Kobe, Hyogo Prefecture
Kitanosaka Ichibankan 7th floor
Google Map

Access

3 minutes walk from Sannomiya Line

Telephone number

078-595-9606

https://four-seasons.jp/

Business hours	Mon	Tue	Wed	Thu	Fri	Sat	Sun
10:00~20:00	◯	◯	◯	◯	◯	◯	◯
Business hours are the same even on holidays Please contact the clinic directly for business hours.

At our clinic, we aim to provide natural rejuvenation and skin beautification treatment for people between the ages of 5 and 28.

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About Four Seasons Cosmetic Dermatology Clinic