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[null,null,null,null,null,"全国健康保険協会管掌　　健康保険【協会けんぽ】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"西崎病院　健康管理センター"]
[]
[null,null,null,null,null,"生活習慣病予防健診申込書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話　(098)  992 - 0089"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX　 (098)  992 - 5995"]
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["事業所名称",null,null,null,null,null,null,null,null,null,null,"：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX:"]
[]
[]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,":"]
["フリガナ",null,null,null,null,"セイ",null,null,null,null,null,null,null,null,null,null,null,null,"メイ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男",null,"生年月日"]
[]
["氏名",null,null,null,null,"姓",null,null,null,null,null,null,null,null,null,null,null,null,"名",null,null,null,null,null,null,null,null,null,null,null,null,"様",null,null,null,"・",null,null,null,"昭和　平成",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女"]
[]
["住所",null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険証",null,null,null,"番号"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"連絡先"]
[]
[]
["希望コース"]
[]
["　 若年健診",null,null,null,null,null,null,"　 一般健診",null,null,null,null,null,null,"　 節目健診",null,null,null,null,null,null,"　 １日ドック",null,null,null,null,null,null,null,"　 ２日ドック",null,null,null,null,null,null,null,"　 子宮がん検診",null,null,null,null,null,null,null,null,"　 乳がん検診",null,null,null,null,null,null,null,"　 骨粗鬆症検診"]
[]
[]
["【　第一希望日　】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【　第二希望日　】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【　第三希望日　】"]
[]
["令和",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,"日",null,"令和",null,null,null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,"日",null,"令和",null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
["【　胃部検査　】",null,null,null,null,null,null,null,null,"*　胃カメラ希望の方は、お薬確認までご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 　【　胃カメラ　経口希望　の方のみ　】"]
[]
[null,null,"　　カメラ (      経鼻  ・      経口 )　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"鎮静剤　： 　　　希望する　　　希望しない"]
[]
[null,null,null,null,null," 歯科の麻酔（ｷｼﾛｶｲﾝ）での気分不良　　  有　・　    無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"\n*　鎮静剤使用する場合、\n一日車の運転はしないことが条件となります。\n","*　鎮静剤追加料金　３，３００円"]
[]
[null,null,null,null,null,"血液サラサラにする薬　    有　・　   無"]
[]
[null,null,"　　胃透視（バリウム）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"希望オプション記入欄"]
[]
[null,null,"　　胃部検査省略　理由番号　【　　　　　　】"]
[]
[null,null,"下記部分を参考に番号を記入してください。"]
[]
["※ 自己都合で胃部検査を希望しない場合は企業健診申込書へ"]
[]
["確定日",null,null,null,null,null,"令和",null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"確認事項"]
[]
[]
[]
[]
["フリガナ",null,null,null,null,"セイ",null,null,null,null,null,null,null,null,null,null,null,null,"メイ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男",null,"生年月日"]
[]
["氏名",null,null,null,null,"姓",null,null,null,null,null,null,null,null,null,null,null,null,"名",null,null,null,null,null,null,null,null,null,null,null,null,"様",null,null,null,"・",null,null,null,"昭和　平成",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女"]
[]
["住所",null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険証",null,null,null,"番号"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"連絡先"]
[]
[]
["希望コース"]
[]
["　 若年健診",null,null,null,null,null,null,"　 一般健診",null,null,null,null,null,null,"　 節目健診",null,null,null,null,null,null,"　 １日ドック",null,null,null,null,null,null,null,"　 ２日ドック",null,null,null,null,null,null,null,"　 子宮がん検診",null,null,null,null,null,null,null,null,"　 乳がん検診",null,null,null,null,null,null,null,"　 骨粗鬆症検診"]
[]
[]
["【　第一希望日　】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【　第二希望日　】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【　第三希望日　】"]
[]
["令和",null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,"日",null,"令和",null,null,null,null,null,null,"年",null,null,null,null,null,null,"月",null,null,null,null,"日",null,"令和",null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
["【　胃部検査　】",null,null,null,null,null,null,null,null,"*　胃カメラ希望の方は、お薬確認までご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 　【　胃カメラ　経口希望　の方のみ　】"]
[]
[null,null,"　　カメラ (      経鼻  ・      経口 )　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"鎮静剤　： 　　　希望する　　　希望しない"]
[]
[null,null,null,null,null," 歯科の麻酔（ｷｼﾛｶｲﾝ）での気分不良　　  有　・　    無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"\n*　鎮静剤使用する場合、\n一日車の運転はしないことが条件となります。\n","*　鎮静剤追加料金　３，３００円"]
[]
[null,null,null,null,null,"血液サラサラにする薬　    有　・　   無"]
[]
[null,null,"　　胃透視（バリウム）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"希望オプション記入欄"]
[]
[null,null,"　　胃部検査省略　理由番号　【　　　　　　】"]
[]
[null,null,"下記部分を参考に番号を記入してください。"]
[]
["※ 自己都合で胃部検査を希望しない場合は企業健診申込書へ"]
[]
["確定日",null,null,null,null,null,"令和",null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"確認事項"]
[]
[]
[]
[]
[]
[null,"★ 胃部検査を省略理由番号 ★"]
[]
[null,null,"① 胃部治療中　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"② 受診前に他の健診等で胃部検査を行っている場合　 "]
[]
[null,null,"③ アレルギー、妊婦等の医学的理由",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"④ 当日の体調（医師の判断）"]
[]
[null,null,"⑤その他（記載お願いします。）"]