In order for the children to have a fun and meaningful school life, we would like to ask foryour cooperation in providing information on your child's heath. This inquiry is intendedfor medical purpose, to examine the state of the heart examination, which is deemedimportant. If there are questions, please do not hesitate to contact either theschoolteachers or any doctors. We request that information be filled as accurately as possible.
Question 1: Until now, have there been any heart problems, such as unusual heartbeat,arrhythmia, and unusual electrocardiogram?
If the answer is yes, please answer the following questions:
When and where was the unusual heart symptom?
What was said about the nature of the unusual symptom? Please circle.
Please circle any of the tests that your child has undergone.
diagnosed with heart problem after close examination
regular hospital visits due to routine medical checkup or medical treatment
despite the doctor's advice for necessary medical treatment, no action was taken
according to the doctor, there was no need for medical treatment
Question 2: Until now, has a doctor ever doubted whether your child had KawasakiDisease fever exceeding 39 degrees and lasting 1 to 2 weeks ?
*If the answer is yes, please answer the following questions:
A When and where was the disease diagnosed?
What kind of medical treatment was undertaken?1
With Kawasaki Disease, were there any difficulties with the heart?
Until now, which test has been undertaken? Please circle those that apply.
cardiac catheterization & coronary angiography's test inserting a catheter into a
coronary artery and put contrast media into it to check
regular hospital visits due to routine medical checkup or medical treatment
despite the doctor's advice for necessary medical treatment, no action was taken
according to the doctor, there was no need for medical treatment
Until now, has any of the following applied?
Feeling painful and feeling an urge to rest after even a light exercise
The pulse sudden became faster, about twice the normal rate
* If the answer is yes, please answer the following questions:
The pulse at that time was 1. irregular 2. regular , about ___ times per
minute and lasted about ___ seconds, minutes, hours
Were there any symptoms of chest pain or cold sweat? 1. Yes
While exercising, there was a contraction in the chest
*If the answer is yes, please answer the following questions:
1 What kind of exercise was it?2 How continuous was the exercise? about
3 While exercising, chest pain takes place?
Has your child ever passed out excluding obvious causes such as traffic accident ?
*If the answer is yes, please answer the following questions:
passing out after enduring a long period of time and becoming sick
passing out after a bath or going to the restroom
Has there been any sudden death of a family member or relative under the
age of 40 as a result of heart disease excluding accident-related deaths ?
Please read it well , and write it down properly. Bring an inspection in school by the
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