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7,0,218,4],[217,5,218,9],[217,10,217,17],[217,18,218,19],[218,10,218,17],[214,0,215,7],[214,8,215,17],[214,31,214,36],[214,37,214,49],[214,52,214,55],[214,56,214,68],[212,31,212,36],[212,37,212,49],[212,52,212,55],[212,56,212,68],[213,31,213,36],[213,37,213,49],[213,52,213,55],[213,56,213,68],[210,14,210,15],[210,52,210,54],[210,55,211,68],[211,1,211,9],[211,10,211,18],[211,19,211,22],[211,52,211,54],[207,60,207,63],[208,52,209,68],[209,4,209,11],[209,31,211,49],[210,1,210,2],[210,3,210,4],[210,5,210,6],[210,7,210,9],[210,10,210,11],[210,12,210,13],[194,58,195,62],[194,63,195,69],[196,1,197,64],[205,32,205,36],[205,38,205,43],[205,52,206,65],[206,1,206,9],[206,31,208,49],[207,2,208,23],[207,56,207,58],[192,53,192,62],[192,63,193,69],[193,10,193,17],[193,44,193,45],[193,47,193,48],[193,50,193,51],[192,30,193,33]],"merged_total":1980,"flags":["formulas_cached_only","merged_cut"]}
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
[null,"全国健康保険協会"]
[null,null,"生活習慣病予防健診申込書",{"$nulls":49},"所在地",null,null,"〒"]
[]
[{"$nulls":4},"【手書き用申込書】",{"$nulls":25},"（ 事業所名称 ）"]
[null,"西暦",null,null,null,"年",{"$nulls":4},"月",null,null,null,"日",{"$nulls":37},"支店名"]
[null,"全国健康保険協会",{"$nulls":17},"支部　行",{"$nulls":32},"（営業所名）"]
[{"$nulls":31},"担当者名",{"$nulls":20},"担当者名"]
["○年度内お一人様1回に限り、協会けんぽが健診費用の一部を補助します。",{"$nulls":30},"電話番号",{"$nulls":20},"電話番号"]
["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
["受付番号\n（記入不要）",{"$nulls":4},"健康保険証\nの番号",{"$nulls":4},"フ　リ　ガ　ナ",{"$nulls":7},"性別",null,"生年月日",{"$nulls":6},"希望する健診の\n種類のいずれかを\n○で囲んでください",{"$nulls":6},"一般健診と併せて受診する\n場合は○で囲んでください",{"$nulls":9},"健診を受ける日",{"$nulls":8},"健　診　機　関　名\n（健診機関コード）",{"$nulls":9},"備　　考"]
[{"$nulls":10},"氏　　　名"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和",{"$nulls":8},"上代成城病院"]
[{"$nulls":46},"年",null,null,"月",null,null,"日","4","3","1","7","3","1","0","1","4","4"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
[null,"全国健康保険協会"]
[null,null,"生活習慣病予防健診申込書",{"$nulls":49},"所在地",null,null,"〒"]
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["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
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["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
[null,"全国健康保険協会"]
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[]
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[null,"全国健康保険協会",{"$nulls":17},"支部　行",{"$nulls":32},"（営業所名）"]
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["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
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["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
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["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
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["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
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["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
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["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
[null,"全国健康保険協会"]
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[]
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[null,"全国健康保険協会",{"$nulls":17},"支部　行",{"$nulls":32},"（営業所名）"]
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["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
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["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
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["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
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["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
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["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
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["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
[null,"全国健康保険協会"]
[null,null,"生活習慣病予防健診申込書",{"$nulls":49},"所在地",null,null,"〒"]
[]
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[null,"全国健康保険協会",{"$nulls":17},"支部　行",{"$nulls":32},"（営業所名）"]
[{"$nulls":31},"担当者名",{"$nulls":20},"担当者名"]
["○年度内お一人様1回に限り、協会けんぽが健診費用の一部を補助します。",{"$nulls":30},"電話番号",{"$nulls":20},"電話番号"]
["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
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["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]
[{"$nulls":30},"（ 事業所所在地 ）","〒",{"$nulls":20},"左記と連絡先が別の場合（支店・営業所）\nは記入してください。"]
[null,"全国健康保険協会"]
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[]
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["健康保険被保険者証の\n保　険　者　番　号",{"$nulls":7},"健康保険被保険者証の\n記　　　号　　",{"$nulls":22},"ＦＡＸ番号",{"$nulls":20},"FAX番号"]
[]
[]
["受付番号\n（記入不要）",{"$nulls":4},"健康保険証\nの番号",{"$nulls":4},"フ　リ　ガ　ナ",{"$nulls":7},"性別",null,"生年月日",{"$nulls":6},"希望する健診の\n種類のいずれかを\n○で囲んでください",{"$nulls":6},"一般健診と併せて受診する\n場合は○で囲んでください",{"$nulls":9},"健診を受ける日",{"$nulls":8},"健　診　機　関　名\n（健診機関コード）",{"$nulls":9},"備　　考"]
[{"$nulls":10},"氏　　　名"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和",{"$nulls":8},"上代成城病院"]
[{"$nulls":46},"年",null,null,"月",null,null,"日","4","3","1","7","3","1","0","1","4","4"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
[{"$nulls":10},"",{"$nulls":16},"一　般　健　診",null,null,"子宮頸がん検診(単独)",null,null,null,"付　加　健　診",null,null,null,"乳がん検診",null,null,"子宮頸がん検診",null,null,"令和"]
[{"$nulls":46},"年",null,null,"月",null,null,"日"]
["※「健診を受ける日」は、あらかじめ受診を希望する健診機関に連絡して受診日を予約してから記入していただく欄です。",{"$nulls":57},"巡回検診車の\n希望の有無",{"$nulls":4},"有　・　無"]
["＜記入上の注意＞"]
["(1)","健診の受診年度において20歳から38歳までの偶数年齢になられる女性の方が、子宮頸がん検診のみを希望される場合は、「子宮頸がん検診（単独）」を○で囲んでください。\nまた、健診の受診年度において36歳・38歳になられる女性の方が、一般健診と併せて子宮頸がん検診を希望される場合は、「一般健診」と「子宮頸がん検診」をそれぞれ○で囲んでください。"]
[]
["(2)","健診の受診年度において40歳以上の偶数年齢になられる女性の方のうち、一般健診と併せて乳がん検診、子宮頸がん検診を希望される場合は「一般健診」と「乳がん検診」、「子宮頸がん検診」をそれぞれ囲んでください。"]
["(3)","一般健診を受診される方のうち、健診の受診年度において40歳、50歳になられる方が、付加健診を希望される場合は、「一般健診」と「付加健診」をそれぞれ○で囲んでください。"]
["(4)","健診機関名は、健診を受ける健診機関名を記入してください。なお、健診機関コード（10桁）は健診実施機関にお尋ねになるか、チラシ等の健診実施機関一覧表などを参照し記入してください。"]
["(5)","検診車による健診受診を希望される事業所にあっては、事業所単位で記入してください。"]
["（注） 今年度において75歳になられる方は、75歳の誕生日から後期高齢者医療制度の被保険者となりますので、誕生日の前日までに受診を終えていただく必要があります。　"]
["（注） この健診結果は、受診者自身の今後の健診・治療及び保健師等による保健指導（特定保健指導を含む）・健康相談並びに個人が識別されない方法での統計・調査研究に限り使われます。　"]
["（注） 健診結果からメタボリックシンドロームの予防が必要と思われる方は、生活習慣を見直すための保健指導（特定保健指導）を受ける必要があります。"]