《Medical Checkup》Special health checkups and Special health-maintenance guidance/Working History
Health Insurance Code and Number

Name of Medical Examinee:

Date of Birth ：-:(Relationship:) Age on the last day of the fiscal year (March 31)【Special health checkups and Special health-maintenance guidance】Questionnaire
1-3※Please select appropriate answer.

Are you currently taking any medication from 'a' to 'c' ? ※Only the case in taking medication under the guidance of doctor'saMedication to lower your blood pressure① Yes② NobMedication to lower your blood sugar level, or taking insulin shots

① Yes

② No

cMedication to lower your cholesterol or neutral fat levels

① Yes

② No

① Yes

② No

① Yes

② No

① Yes

② No

① Yes

② No

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6
7

Have you ever been diagnosed with a stroke (cerebral hemorrhage,infarction, etc.) by a physician or received treatment for it ?
Have you ever been diagnosed with heart disease (angina, myocardialinfarction, etc.) by a physician or received treatment for it ?
Have you been diagnosed with chronic kidney disease (CKD) or renal/kidney
failure by a physician, or are you receiving medical care for these diseases ?
Have you ever been diagnosed with anemia by a physician ?
Are you a regular smoker?
You are considered to be a regular smoker if both of the following criteria apply:

8Criterion 1: You have smoked within the past month
Criterion 2: You have smoked for over six months at any point in your life or havesmoked a total of over 100 cigarettes over the course of your life

91011
12

：

①Yes (both criteria 1 and 2 apply to you)
② I used to smoke, but I have not smoked within the past month(only criterion 2 applies)③No (neither criteria 1 nor 2 apply)

Have you gained 10 kg or more since you were 20 years old ?
Do you work out hard enough that you lightly sweat for more than 30
minutes a session, at least twice a week over a year?
In your daily life, do you walk or conduct an equivalent physical activity
for more than an hour each day?
Do you walk faster than people of the same sex who are nearly your age ?

① Yes

② No

① Yes

② No

① Yes

② No

① Yes

② No

① You can chew and eat anything.
13

Which situation below best describes your condition when chewing food ?

② There are parts of your teeth, gums and dental occlusion that you areconcerned about, and it is difficult to chew.
③ You are largely unable to chew.

14

Do you eat faster than others ?

15

Do you eat dinner within two hours of going to bed 3 times a week or more ?

1617① Fast① Every day

breakfast-lunch-dinner?
Do you skip breakfast 3 times a week or more ?

(* Select "I no longer drink" if you were a habitual drinker that drank once or more per

How much do you drink per day? 1 cup of sake (15% ABV, 180 ml) isequivalent to:
500 ml of beer (5% ABV),Roughly 110 ml of shochu (25% ABV),Roughly 180 ml ofwine (14% ABV),60 ml of whiskey (43% ABV),500 ml of canned chuhai (5% ABV) or③ Slow② No② Sometimes① Yes

month in the past but have not drunk alcohol within the past one-year period.)

19

① Yes

Are you intaking sweets or any food outside of the standard 3-meal

How often do you drink alcohol (sake, shochu, beer, liquor, etc.)?
18② Normal③ Rarely② No①Every day②5 to 6 times a week

③3 to 4 times a week

④1 to 2 times a week

⑤1 to 3 times a month⑥Less than once per month⑦I no longer drink⑧I don't drink (I can't drink)①Less than a cup④3 to 5 cups

② 1 to 2 cups

③ 2 to 3 cups

⑤5 cups or more

350 ml of canned chuhai (7% ABV)20

Do you get enough rest from sleeping ?

① Yes

② No

① I do not intend to improve them.
② I intend to improve them (within 6 months or so).
21

Would you like to improve your life habits, such as exercising and diet ?

③ I intend to improve them in the near future (within a month or so),and I am starting to improve them a bit at a time.
④ I have already been working on them (for less than 6 months).
⑤ I have already been working on them (for more than 6 months).

22

Have you ever received specific health guidance about improving your lifehabits?

① Yes

② No

① Yes

② No

Working history *Only for Insured person
Working History (within 128 characters)
1*Please fill in the type of job, number of years, etc.
Workplace is not required.
e.g.)5 years of sales experience
Do you have any working history with hazardous materials(*)?
(*)hazardous materials

2

Dust work, organic solvent handling work, lead handling work,
specific chemical substance handling work, radiation exposure work,
noise workplace, etc.