Questionnaire (colorectal cancer screening, tuberculosis screening, electrocardiogram, renal function test, uric acid test, hepatitis virus screening)
Updated: March 30, 2023
For those undergoing colorectal cancer screening, tuberculosis screening, electrocardiography, renal function testing, uric acid testing, and hepatitis virus screening
- A medical questionnaire is required for the above examinations. Please fill out the questionnaire in advance and bring it to the medical institution.
- Medical questionnaires are available on the 2nd floor of the main office of the city hall (Welfare Division), Hirao/Wakabadai Branch Office, and Health Center, so please use them. You can also download it from here.
Note: There are 2 questionnaires. Please fill out both sheets and bring them to the medical institution.
Medical questionnaire (the surface) (PDF: 116KB)
Medical questionnaire (the back side) (PDF: 125KB)
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Inquiries about this page
Inagi City Welfare Department Health Division
112-1 Hyakumura, Inagi City, Tokyo (inside the Inagi Health Center)
Phone: 042-378-3421 Fax: 042-377-4944
