For family members other than spouses
aged 40 and up in fiscal year 2024
(until the day before one's 75th birthday)

Fujitsu Health Insurance Society 2024 Edition

Health Checkup Request Form (Family Member 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 HealthCenters."
・When making an appointment, be sure to tell them it is for a "Fujitsu Health Insurance Society Free Family
Member Health Checkup."(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.

(3) Examination

If additional tests other than those listed among the "Examination Items" on the reverse side are performed, youwill be required 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 medicalinstitution.
* 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.

Date of Checkup(YYYY/MM/DD)

Type of Checkup

Specific HealthCheckup//・You can receive a specific health checkup without any co-payment.
・For the examination items, please see the reverse side.

Health insurance card
code

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

Name

Must be a dependent of Fujitsu HealthInsurance as of the date of examination.
Must be examined by the day before one's
75th birthday.

Date 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

[Family Member Health Checkup]
Examination Item

Details of Examination
Physician examination, subjective symptoms, other symptoms, medical history(medication and smoking history)

Measurement

Height, weight, BMI, abdominal circumference, blood pressureUrinalysis

Proteins, sugars

Blood test

Specific Health Checkup

Medical examination

Liver function

AST (GOT), ALT (GPT), γ-GTP

LipidsNeutral fat, HDL cholesterol, LDL cholesterol

Glucose metabolism

Fasting blood glucose or HbA1c (whichever is performed)*1To 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.
・Please be sure to conduct this examination because it is a specific health checkup item.