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B With a partner, take turns playing the roles of nurse and patient. Ask each other the questions you need
to ask to fill out the application form below. One partner is Robert Jones, the other is Mary Woods.
Robert William Jones
D.O.B. 9/12/70
23-42 Shiizaki, Sakae-machi, Inba-gun, Chiba-ken, 289-1222
Tel.: 0475-72-1234
Businessman
Stomachache
Came to this hospital before with back pain in October, 2012
Mary Margaret Woods
D.O.B. 7/31/80
7512 22nd Ave. N.W.
Portland, Oregon 98115-4706
Tel.: (425) 791-8836
Housewife
Sprained ankle
First time at this hospital
APPLICATION FORM
Last Name
month
Date of Birth
Address
Telephone
Occupation (Circle one)
month
Date
First Name
day
year
day
year
Middle Name
Sex
M / F
years old
Which department would you like to go to? (Circle one)
1 Self-employed
01
Internal Medicine
11
Obstetrics & Gynecology (OB/GYN)
2 Farmer/Skilled worker
02
Pediatrics
12
Ophthalmology (Eye doctor)
3 Civil servant
03
Surgery & Treatments
13
Dermatology (Skin doctor)
4
LO
00
5
6
Businessman
Student
Housewife
04
Orthopedics
14
Nutrition & Dietetics
05
Neurology
15
Radiology (X-ray)
06
Urology
16
Oral Surgery
7 Unemployed
07
Respiratory Medicine
17
Cardiology
8 Hospital employee
18
Plastic Surgery
08
Psychiatry
9
09
Otolaryngology (ENT)
19
Dentistry
Other: (Please specify):
10
Anesthesiology
20
Allergy & Immunology
1. NO
Have you ever been to this hospital before?
2. YES (Year:
) (Department:
)
