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英文意見書サンプル(ヤンヒーモデル)  

事例 「他院で診断とホルモン治療を受け続けていたものの、海外での SRS を受けるにあたり英
文診断書の発行を断られた」というケースにおける意見書例

Medical Opinion Statement
(意 見 書 )
SAMPLE
 I asked Mr. SAMPLE NAME sufficient adequate questions to evaluate his sexual
identity concerning to GID diagnosis and performed re-confirmation over his intent
to take SRS out of JAPAN and a inclination of taking his life as “ male ” for the rest
of life. I am satisfied by his answer about the emphatic belief of himself taking SRS
and the inclination. In my opinion, it is reasonable to perform SRS toward him as
long as it is done out of Japan and Japanese jurisdiction.
Yours sincerely,
敬具

SAMPLE

Date:
Signature:

SAMPLE

SAMPLE DOCTOR, MD, PhD
Chief physician,
SAMPLE CLINIC
Disclaimer :
1. This diagnosis is based sololy on oral concultation and his life history statement in his own writing.
2. Japanese regulation including the guidline concerning GID diagnosis and evaluating the appropriateness for
SRS requires additional examination and one more diagnosis by third party physician in addition to this
diagnosis and certificate. 
3. No one may not perform SRS surgery based upon this diagnosis and certificate in Japan geograficaly nor in
Japanese jurisdiction legally.

このサンプルの文面は架空の特定のケースに即して作成されたものであり、この文
面を剽窃して文書を作成して宛先海外医療機関に提出すると、不適正条件に該当
するとしてSRSの実施を拒否されますのでご注意ください。さらに、実際には各宛先
医療機関ごとの様式要件と記載事項要件があります。

英文意見書サンプル(ヤンヒーモデル)  
事例 「他院で診断とホルモン治療を受け続けていたものの、海外での SRS を受けるにあたり英文診断書の発行を断られた」というケースにおける
意見書例