Osato Medical Clinic Health Checkup / Comprehensive Medical Exam Plan

Health Checkup Application Form Medical Questionnaire Insurance Claim Agreement New Patient Form (new patients only)
Please download and complete the forms, then send them as attachments in reply to the application confirmation email.

Reference Age			18-29	30-39	40-49	50+	Management
Basic Plan
1	General Internal Medicine Exam	Medical history analysis	●	●	●	●	●
		Physician consultation, auscultation/percussion, palpation	●	●	●	●	●
		Blood pressure	●	●	●	●	●
		Height/weight/waist measurement	●	●	●	●	●
2	Blood tests	General status: Total protein, albumin, A/G ratio	●	●	●	●	●
		Liver function: Total bilirubin, SGOT, SGPT, ALP, r-GTP, LDH	●	●	●	●	●
		Kidney function: BUN, creatinine	●	●	●	●	●
		Lipid metabolism: Total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol	●	●	●	●	●
		Glucose metabolism: Fasting blood glucose, HbA1c	●	●	●	●	●
		Minerals/Ions: Calcium, sodium, potassium, chloride	●	●	●	●	●
		Gout: Uric acid	●	●	●	●	●
		Thyroid function: TSH, FT4, FT3	●	●	●	●	●
		Complete blood count	●	●	●	●	●
		Vitamin D	●	●	●	●	●
3	Urinalysis	pH, specific gravity, protein, ketones, glucose, occult blood, bilirubin, urobilinogen, urine sediment	●	●	●	●	●
4	Stool test	Fecal occult blood	●	●	●	●	●
Optional Test
5	Vision test	Vision test	●	●	●	●	●
6	Hearing test	Hearing test	●	●	●	●	●
7	Pulmonary function	Spirometry		●	●	●	●
8	Cardiac function	ECG (resting)		●	●	●	●
9	Chest X-ray	Direct radiography		●	●	●	●
10	Gynecological exam	Cervical cancer cytology	●	●	●	●	●
		HPV test		●	●	●	●
		Mammogram			●	●	●
11	Abdominal ultrasound	Gallbladder, liver, kidneys, pancreas, spleen			●	●	●
12	Carotid ultrasound	Carotid artery					●
13	Hepatitis	Hepatitis B	●	●	●	●	●
		Hepatitis C	●	●	●	●	●
14	Additional blood tests	Prostate tumor marker (PSA) MALE				●	●
		Ovarian tumor marker (CA-125) FEMALE				●	●
		Syphilis	○	○	○	○	○
		Herpes	○	○	○	○	○
15	Other tests	Chlamydia	○	○	○	○	○
		Gonorrhea	○	○	○	○	○
16	GI tests	Upper GI endoscopy (esophagus, stomach, duodenum)			○	○	○
		Colonoscopy (entire colon, sigmoid colon, rectum)				○	○