For dependent spouses(until the day before one's 75th birthday)
Age requirement: As of March 31, 2025

Fujitsu Health Insurance Society 2024 Edition

Health Checkup Request Form (Spousal Health Checkup)
Please be sure to read this form.
You may receive one free health checkup during the fiscal year (from April 1 to March 31 of thefollowing year).
* Please note that a second examination of the same type will be at your own expense.

Flow from appointment and examination to receipt of results(1) Appointment

・Please apply by calling the health center of your choice from among the enclosed "List of Contracted Health Centers."
・When making an appointment, be sure to tell them it is for a "Fujitsu Health Insurance Society Free Spousal HealthCheckup."(2) Preparation

・The health center may send you a health checkup kit or other materials. If you have any questions, please ask thehealth center.
・Please prepare according to the health center's guidance.
・Please undergo a checkup on the day of your appointment. (In the unlikely event that you are unable to do so, be sure
to contact the health center.)・Please bring your Health Insurance Card and this Health Checkup Request Form.
For those who are unable to undergo the "Gastric X-ray test":Those who have allergic symptoms to barium or who have been previously diagnosed with intestinal
obstruction or diverticulitis of the colon may request an "examination by gastroscopy" at the contracted healthcenter. However, please contact the contracted health center to confirm whether such an examination isavailable and how to proceed with said examination. Any costs incurred for changes or additions are to becovered by the examinee.

(3) Examination

If additional tests other than those listed among the "Examination Items" on the reverse side are performed, you will berequired to bear the additional costs. There is no Fujitsu Health Insurance subsidy for such costs.
If you wish to undergo additional tests, please check with the health center regarding the amount you will be required
to pay and the payment method.
(4) Receipt of result
notification

・You will receive a notice of the results of the health checkup from the health center at a later date.
・If the results indicate that you should undergo a full examination, be sure to do so at a medical institution.
* Such further examinations and treatment are covered by insurance.

Form to Be Completed by the Examinee
Please complete the form in this frame and submit it to the health center on the day of the checkup.
(YYYY/MM/DD)

Date of Checkup/

Lifestyle-related disease checkup

Lifestyle-related diseases(including cancer screenings)□ 39 and under (including lung cancer screening)□ 40 and up (including lung, colon and stomach cancer screenings)

Breast cancer screening

Type of Checkup
Please check the appropriatebox (☑).

□ Breast cancer screening + Cervical cancer screening

Mammography or breast ultrasound(echography)(Breast cancer screening items:□ Mammography□ Breast ultrasound (echography))□ Breast cancer screening only

Cervical cancer screening(Breast cancer screening items:□ Mammography □ Breast ultrasound (echography))

Cervical cytology (physician-collected)
Health insurance cardcode/

□ Cervical cancer screening only

Health insurance card number<Requirements for Health Checkups>(1)(2)

Must be a dependent of Fujitsu Health Insurance forspouses as of the date of the examination.
Must be examined by the day before one's 75thbirthday.

NameDate of Birth(YYYY/MM/DD)/Examinee/() years oldAddress and Contact Information(〒-)(Contact Phone No.

--)* Personal information collected using this form will not be used for any purpose other than to implement Fujitsu Health Insurance Society's health services. The
information will be properly managed in accordance with the Personal Information Protection Law.
* Fujitsu Health Insurance Society health checkup business is entrusted to Best Life Promotion, a wholly owned group company of Fujitsu.
Do not think you are fine merely because you underwent an annual health checkup;
if you have noticed symptoms of concern, we recommend seeking a medical consultation as soon as possible.

Fujitsu Health Insurance Society / Service provided by Best Life Promotion

[Spousal Health Checkup (Dependent)]
Details of Examination

Examination Item
Medicalexamination

Physician examination, subjective symptoms, other symptoms,medical history (medication and smoking history)
Height, weight, BMI, blood pressure, visual acuity

Measurement

Abdominal circumference

39 and Under

40 and Up

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Hearing (1,000 Hz, 4,000 Hz)－○Cancer Screenings

Proteins, sugars, sediment○○Generalblood

White blood cell count, platelet count○○AnemiaRed blood cell count, hemoglobin level, hematocrit

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Liver
function

AST (GOT), ALT (GPT), γ-GTP○○

Total protein, total bilirubin－○

LipidsTriglycerides, HDL cholesterol, LDL cholesterol, total cholesterol○○

Glucosemetabolism

Fasting blood glucose or HbA1c (whichever is performed)*1○○

KidneyfunctioneGFR, serum creatinine－○

Uric acid

Uric acid○○

Physiology

Electrocardiogram－○

Lung cancer

Chest X-ray test○○

Colon cancer

Fecal occult blood test－○－○Urinalysis

Blood test

Lifestyle-related Disease Checkup

Implemented at somecenters

Gastric X-ray (barium) test

Stomachcancer* Note on barium tests:
After the test, barium may harden in the intestine, causing an intestinal
obstruction (ileus). After the examination, please follow the health center'sinstructions to ensure the smooth evacuation of the barium.
In addition, if you are undergoing treatment for a gastrointestinal disorder,
have ever received treatment for a gastrointestinal disorder, or have everexperienced allergic symptoms attributable to barium, be sure to inform thehealth center at the time of your appointment.

Examination Item

Details of Examination

All Ages

Palpation will be conducted upon the examinee's request. However,depending on the contract with the health center, it may not be performed.

Upon the examinee's request

Breast examination
Gynecological Checkup

BreastcancerCervicalcancer△Mammography or breast ultrasound (echography)
In principle, only one of these two examinations will be conducted. If you wish
to have both examinations, please contact the health center directly. It ispossible to undergo both examinations (although some health centers cannotaccommodate this), but the cost of one of the two examinations must becovered by the examinee. Please note that some health centers may only
provide mammography or breast ultrasound (echography).

Cervical cytology (physician-collected)

To the Health Center*1 Fasting blood glucose and HbA1c should be performed according to the contract.
Always perform HbA1c if fasting blood glucose cannot be obtained.
・For specific health checkups, please be sure to perform the underlined items.

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