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{"sheet":"疾病予防補助金","index":0,"n_rows":44,"n_cols":34,"rows_kept":44,"cut":false,"hidden":false,"merged":[[24,30,25,32],[24,33,25,33],[26,1,26,5],[28,1,28,2],[29,1,30,2],[29,3,30,8],[29,9,30,9],[36,1,36,5],[36,10,36,11],[36,12,36,14],[36,15,36,33],[25,10,25,11],[30,10,30,11],[35,10,35,11],[31,1,31,5],[31,10,31,11],[31,12,31,14],[31,15,31,33],[34,10,34,11],[34,12,34,16],[34,30,35,32],[34,33,35,33],[26,10,26,11],[26,12,26,14],[27,1,27,2],[27,3,28,8],[27,9,28,9],[27,10,28,11],[27,12,28,16],[27,17,28,29],[27,30,28,33],[29,10,29,11],[29,12,29,16],[29,30,30,32],[29,33,30,33],[26,15,26,33],[39,2,39,33],[40,2,40,33],[34,1,35,2],[34,3,35,8],[34,9,35,9],[32,9,33,9],[32,10,33,11],[32,12,33,16],[32,17,33,29],[32,30,33,33],[32,1,32,2],[32,3,33,8],[33,1,33,2],[24,1,25,2],[24,3,25,8],[24,9,25,9],[22,1,22,2],[22,3,23,8],[22,9,23,9],[22,10,23,11],[22,12,23,16],[22,17,23,29],[24,10,24,11],[24,12,24,16],[22,30,23,33],[23,1,23,2],[17,17,18,29],[17,30,18,33],[18,1,18,2],[19,1,20,2],[19,3,20,8],[19,9,20,9],[17,1,17,2],[17,3,18,8],[17,9,18,9],[17,10,18,11],[17,12,18,16],[19,10,19,11],[19,12,19,16],[19,30,20,32],[19,33,20,33],[21,1,21,5],[21,10,21,11],[21,12,21,14],[21,15,21,33],[20,10,20,11],[0,0,0,33],[12,1,12,2],[12,3,13,8],[12,9,13,9],[12,10,13,11],[12,12,13,16],[12,17,13,29],[12,30,13,33],[13,1,13,2],[4,26,4,32],[2,1,2,6],[3,1,3,6],[11,1,11,33],[3,7,3,23],[5,26,9,32],[2,7,2,23],[4,1,4,23],[5,1,5,23],[7,1,9,7],[7,8,7,23],[8,8,8,23],[9,8,9,23],[16,10,16,11],[6,1,6,2],[14,30,15,32],[16,12,16,14],[16,15,16,33],[16,1,16,5],[10,26,10,32],[14,10,14,11],[14,1,15,2],[14,3,15,8],[14,9,15,9],[14,33,15,33],[14,12,14,16],[15,10,15,11]]}
["疾病予防事業補助金交付申請書"]
[null,"※　太枠内を記入してください。"]
[null,"事業所記号",null,null,null,null,null,"事業所の名称"]
[]
[null,"申請者記入欄兼委任状(事業所振込）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【健保受付欄】"]
[null,"疾病予防事業補助金の交付申請、及び事業所の保険給付金受領代理人に補助金の受領を委任します。"]
[null,"令和",null,null,"年",null,"月",null,"日"]
[null,"申請者の住所・氏 名"]
[]
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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,"玩具人形健康保険組合"]
[null,"※　続柄欄は本人（被保険者）又は家族（被扶養者）、種目欄は受診した種目それぞれ〇で囲ってください。"]
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[]
[null,"【注　意】"]
[null,"※1.　","受診者記入欄に複数の被保険者、被扶養者を記入する場合は申請者記入欄に事業所名・事業主名をそれぞれ記入してください。"]
[null,"※2.　","請求期限は当該年度中に実施した分の請求は当該翌年度の4月30日までとします。なお、期限を過ぎた場合は支給できませんのでご注意ください。"]
[null,"※3.　","申請の際、領収書原本と健診結果表コピー、40歳以上（※年度末年齢）の方は問診表を添付してください。"]
[null,"※4.　","申請書および添付書類の取扱いは限られた目的（保健指導等）のため使用いたします。"]
[null,"※5.　","各年度の期間は4月1日から翌年3月31日までです。"]

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[null,"疾病予防事業補助金交付申請書（続紙）"]
[null,"※受診者が6名以上いる場合は続けてこの用紙に記入してください。"]
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[null,"保険証",null,"受診者氏名",null,null,null,null,null,"続柄","年　齢",null,"健診日",null,null,null,null,"種　　目",null,null,null,null,null,null,null,null,null,null,null,null,"健診料金"]
[null,"の番号"]
[null,null,null,null,null,null,null,null,null,"本人　　・　　家族",null,null,"令和",null,null,null,null,"定期健診",null,"・","生活習慣病健診",null,null,null,"・","婦人生活習慣病健診",null,null,null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,"才",null,null,"．",null,"．",null,"人間ドック",null,null,"・","人間ドック＋婦人科"]
[null,"生年月日　昭和・平成　　　",null,null,null,null,null," .",null,". ",null,null,"医療機関名　"]
[null,"保険証",null,"受診者氏名",null,null,null,null,null,"続柄","年　齢",null,"健診日",null,null,null,null,"種　　目",null,null,null,null,null,null,null,null,null,null,null,null,"健診料金"]
[null,"の番号"]
[null,null,null,null,null,null,null,null,null,"本人　　・　　家族",null,null,"令和",null,null,null,null,"定期健診",null,"・","生活習慣病健診",null,null,null,"・","婦人生活習慣病健診",null,null,null,null,null,null,null,"円"]
[null,null,null,null,null,null,null,null,null,null,"才",null,null,"．",null,"．",null,"人間ドック",null,null,"・","人間ドック＋婦人科"]
[null,"生年月日　昭和・平成　　　",null,null,null,null,null," .",null,". ",null,null,"医療機関名　"]
[null,"※　続柄欄は本人（被保険者）又は家族（被扶養者）、種目欄は受診した種目それぞれ〇で囲ってください。"]

{"sheet":"問診票","index":2,"n_rows":30,"n_cols":3,"rows_kept":30,"cut":false,"hidden":false,"merged":[[0,1,0,2],[18,0,19,0],[18,1,19,1],[27,0,28,0],[27,1,28,1]]}
[null,"問診票（40歳以上記入）"]
[null,"記号　　　　　　　　　　番号　　　　　　　　　　本人・家族","配偶者　　　　　　　あり　　　なし"]
[null,"（フリガナ）","同居の家族　　　　　　　　　　人"]
[null,"氏名"]
[null,"問診項目","回答記入欄（Vチェック）"]
[null,"1-3現在、aからｃの薬の使用の有無"]
["1a","血圧を下げる薬 ","　 はい  　　 いいえ"]
["2b","血糖を下げる薬又はインスリン注射","　 はい  　　 いいえ"]
["3c","コレステロールや中性脂肪を下げる薬 ","　 はい  　　 いいえ"]
[4,"医師から、脳卒中（脳出血、脳梗塞等）にかかっていると                       いわれたり、治療を受けたことがありますか。","　 はい  　　 いいえ"]
[5,"医師から心臓病（狭心症、心筋梗塞等）にかかっていると                       いわれたり、治療を受けたことがありますか。","　 はい  　　 いいえ"]
[6,"医師から、慢性腎臓病や腎不全にかかっていると いわれたり、                                              治療（人工透析など）を受けていますか。","　 はい  　　 いいえ"]
[7,"医師から、貧血といわれたことがある。 ","　 はい  　　 いいえ"]
[8,"現在、たばこを習慣的に吸っている。                                                   （※「現在、習慣的に喫煙している者」とは、「合計100 本以上、又は6ヶ月以上吸っている者」であり、最近1 ヶ月間も吸っている者）","　 はい  　　 いいえ"]
[9,"20歳の時の体重から10kg 以上増加している。 ","　 はい  　　 いいえ"]
[10,"1回30分以上の軽く汗をかく運動を週2日以上、1年以上実施","　 はい  　　 いいえ"]
[11,"日常生活において歩行又は同等の身体活動を1日1時間以上実施","　 はい  　　 いいえ"]
[12,"ほぼ同じ年齢の同性と比較して歩く速度が速い。","　 はい  　　 いいえ"]
[13,"食事をかんで食べる時の状態はどれにあてはまりますか。","□ 何でもかんで食べることができる  　　　　　　□ 歯や歯ぐき、かみあわせなど気になる部分"]
[null,null,"　 があり、かみにくいことがある　　　　　　　　　　□ ほとんどかめない"]
[14,"人と比較して食べる速度が速い。 ","　 速い     　 ふつう     　　遅い"]
[15,"就寝前の2時間以内に夕食をとることが週に3回以上ある。","　 はい  　　 いいえ"]
[16,"朝昼夕の3食以外に間食や甘い飲み物を摂取していますか。","　 毎日  　　 時々　   　ほとんど摂取しない"]
[17,"朝食を抜くことが週に3回以上ある。 ","　 はい  　　 いいえ"]
[18,"お酒（日本酒、焼酎、ビール、洋酒など）を飲む頻度","□ 毎日  　□ 時々                                                                                                                                     □ ほとんど飲まない（飲めない）"]
[19,"飲酒日の１日当たりの飲酒量　　　　　　　　　　　　　　　　　　　　　日本酒１合（180ｍｌ）の目安：ビール500ｍｌ、焼酎（25度）110ｍｌ、ウイスキーダブル一杯（60ｍｌ）、ワイン2杯（240ｍｌ）","□ １合未満 \n□ １～２合未満\n□ ２～３合未満 \n□ ３合以上"]
[20,"睡眠で休養が十分とれている。 ","　 はい  　　 いいえ"]
[21,"運動や食生活等の生活習慣を改善してみようと思いますか。","□ 改善するつもりはない \n□ 改善するつもりである（概ね６か月以内）\n□ 近いうちに（概ね１か月以内）改善する"]
[null,null,"    つもりであり、少しずつ始めている\n□ 既に改善に取り組んでいる（６か月未満）\n□ 既に改善に取り組んでいる（６か月以上）"]
[22,"生活習慣の改善について保健指導を受ける機会があれば利用しますか。","　 はい  　　 いいえ"]