For all members(until the day before one's 75th birthday)

Fujitsu Health Insurance Society 2024 Edition

Health Checkup Request Form (Checkup for Special Retirement)
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 Health Checkup
for Special Retirement."(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, besure 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 health center.
However, please contact the contracted health center to confirm whether such an examination is available andhow to proceed with said examination. Any costs incurred for changes or additions are to be covered by theexaminee.

(3) Examination

If additional tests other than those listed among the "Examination Items" on the reverse side are performed, you will
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 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.

Date of Checkup

Type of Checkup(YYYY/MM/DD)//

Lifestyle-relateddiseases(including cancerscreenings)

・Lifestyle-related disease checkups (including lung, colon, and stomach cancer screenings)
are available at no cost to the examinee.
*For men, prostate-specific antigen (PSA) tests are available.
・For the examination items, please see the reverse side.

Gynecological checkup

・Breast and cervical cancer screenings are available.
・To undergo these examinations, please use the Health Checkup Request Form (InsuredGynecological Checkup).

Health insurance cardcode９００

Health insurance card number

１<Requirements for Health Checkups>
(1)

(2)

Name

Must be an insured person of Fujitsu Health
Insurance for special retirement as of the dateof the 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[Checkup for Special Retirement]
Details of Examination

Examination Item

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

Measurement

Height, weight, BMI, abdominal circumference, blood pressure,visual acuity, hearing (1,000 Hz, 4,000 Hz)

Urinalysis

Proteins, sugars, sediment

Blood test

Lifestyle-related Disease Checkup

Medical examination

General blood

White blood cell count, platelet countAnemiaRed blood cell count, hemoglobin level, hematocrit

Liver function

AST (GOT), ALT (GPT), γ-GTP, total protein, total bilirubin

LipidsTriglycerides, HDL cholesterol, LDL cholesterol, total cholesterol

Glucose metabolism

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

Kidney function

eGFR, serum creatinine

Uric acid

Uric acid

Physiology

Electrocardiogram
Fundoscopy

Lung cancer

Chest X-ray test

Colon cancer

Fecal occult blood test

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

Prostate cancer * Men only

Gastric X-ray (barium) test

Prostate-specific antigen (PSA) test

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.