《Medical Checkup》Appointment details & Special health checkups and Special health-maintenance guidance, and Stomach ABC screening Questionnaire

Health Insurance Code and Number

Name of Medical Examinee:

Date of Birth ：-:(Relationship:)Age on the last day of the fiscal year (March 31)：

Appointment details
Name of Medical Institution
Date of Appointment
for checkup
Checkup Course,【Basic Courses】 Select one corresponding to your age. ※Some basic courses and some medical institutions requireincl. option tests

your self-payment (cash or points). In detail, refer to the Contracted Medical Institutions List.

Basic Courses

Check

Eligibility[complete] health checkups + Upper endoscope
32 or over[complete] health checkups + Stomach x-ray[general] health checkups[general] health checkups + Upper endoscope

23-31[general] health checkups + Stomach x-ray【Option Examination】
Option Examination

Check

Self-payment

Stomach ABC screening(Stomach cancer risk check)

Eligibility
This is a blood test that measures the risk of

2,000 JPY (P)developing stomach cancer

Ultrasound(Echo)
Breast Canser

None
Mammography

Female(X-rey)
Cervical Canser

None

Prostate Canser (PSA)None

Male age 50 or overOther（How to pay the self-payment）□Cash (Pay directly to the medical medical institution on the health checkup day.)□Point※Please select one.
※Some medical institutions cannot be available
to either payment.

Transcript of results※If you do not have enough points to pay the self-payment, pay the excess portion directly

to the medical medical institution on the health checkup day.
※Please select one.

□Japanese□

EnglishAddress (to which the examination kit andresults will be sent)※Please ensure you include the postal code.

Telephone number※There will be direct communication from
the Medical Institution. Please designateda day-time telephone number.

Method for sending the 'Confirmation Slipfor Medical Checkup'※Please select one and draw a circle in thenecessary items.

★Important★

e-mail （ mail address :Fax（））

Post (Will be sent to the above address)

Results of Medical Checkup Report※Application for medical checkup cannot be made without consent to submit to the Health Insurance Society. 「✔」must be inserted.
□ I agree to the Medical Institution providing the results of the medical checkup (including repeated checkups)
to the Health Insurance Society.

《Medical Checkup》Appointment details & Special health checkups and Special health-maintenance guidance, and Stomach ABC screening Questionnaire

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 pressure

① Yes

② Nob

Medication to lower your blood sugar level, or taking insulin shots

① Yes

② No

c

Medication 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

45

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, myocardial
infarction, 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

9101112：①Yes (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 Yes② No① 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 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 permonth in the past but have not drunk alcohol within the past one-year period.)② Normal① 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.)?
18① Fast③ Slow② No② Sometimes① Yes③ 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)

How much do you drink per day? 1 cup of sake (15% ABV, 180 ml) isequivalent to:19500 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) or①Less 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 Yes② No