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[null,null,null,null,null,"精神科外来　問診票",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"天王病院",null,null,null,null,null,{"$f":"TODAY()","v":"2023-05-09"}]
[]
["患者さん",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同伴者氏名",null,null,null,null,null,"続柄"]
["氏名",null,null,null,null,null,null,null,null,null,"性別(※)",null,"生年月日",null,null,null,null,null,"年齢"]
[null,null,null,null,null,null,null,null,null,null,"男",null,null,null,null,null,null,null,{"$f":"IF(M5=\"\",\"\",DATEDIF(M5,AE1,\"Y\"))","v":""}]
[null,null,null,null,null,null,null,null,null,null,"女"]
[]
["記載者\n氏名",null,null,null,null,null,null,null,null,null,null,null,"患者さんとの関係"]
[]
[]
["主介護者\n（※）",null,null,"１．記載者と同じ",null,null,null,null,null,"２．記載者とは別の方",null,null,null,null,null,null,"⇒","氏名",null,null,null,null,null,null,null,"続柄"]
[]
["主介護者\n住所",null,null,"〒",null,null,"ー",null,null,null,null,null,null,null,null,null,null,null,null,"自宅電話"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"携帯電話"]
["介護保険\n（※）",null,null,"あり ⇒",null,null,"要介護",null,null,1,2,3,4,5,"要支援",null,null,1,2,"期限",null,null,null,null,null,null,null,null,"迄"]
[null,null,null,"申請中 ⇒",null,null,"申請日"]
[null,null,null,"未申請"]
["介護\nサービス\n利用状況",null,null,"サービス名（※）",null,null,null,null,null,null,null,"利用曜日",null,null,null,null,"サービス名（※）",null,null,null,null,null,null,null,"利用曜日"]
[null,null,null,"ﾃﾞｲｻｰﾋﾞｽ（通所介護）",null,null,null,null,null,null,null,null,null,null,null,null,"訪問リハビリ"]
[null,null,null,"ﾃﾞｲｹｱ（通所ﾘﾊﾋﾞﾘ）",null,null,null,null,null,null,null,null,null,null,null,null,"訪問看護"]
[null,null,null,"ショートステイ",null,null,null,null,null,null,null,null,null,null,null,null,"訪問介護"]
["ｹｱ\nﾏﾈｰｼﾞｬｰ",null,null,"事業所名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ｹｱﾏﾈｰｼﾞｬｰ\n氏名"]
[]
[]
["ご家族について"]
["兄弟姉妹",null,null,"患者さんは",null,null,null,null,"人兄弟の",null,null,null,"番目",null,"子供",null,null,null,null,null,"人"]
["配偶者",null,null,"年齢",null,null,null,null,null,"歳",null,null,null,null,1,"氏名",null,null,null,null,null,null,null,"歳","職業"]
[null,null,null,"健康\n状態\n（※）",null,"健康",null,null,null,null,null,null,null,null,null,"住所"]
[null,null,null,null,null,"病気",null,null,"病名",null,null,null,null,null,null,"電話",null,"自宅",null,null,null,null,null,"携帯"]
[null,null,null,null,null,"死亡",null,null,"死因",null,null,null,null,null,2,"氏名",null,null,null,null,null,null,null,"歳","職業"]
[null,null,null,"職業",null,null,null,null,null,null,null,null,null,null,null,"住所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話",null,"自宅",null,null,null,null,null,"携帯"]
["患者さんと\n同居の方",null,null,"＊「妻」「長男」「次女」等続柄でご記入下さい",null,null,null,null,null,null,null,null,null,null,3,"氏名",null,null,null,null,null,null,null,"歳","職業"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話",null,"自宅",null,null,null,null,null,"携帯"]
[]
["患者さんについて"]
["出生地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主な職歴",null,1,null,null,null,null,null,null,"期間",null,null,null,"年"]
["育った所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,null,null,null,null,null,null,"期間",null,null,null,"年"]
["結婚歴(※)",null,null,"あり",null,null,null,null,null,"歳",null,"なし",null,null,null,null,null,3,null,null,null,null,null,null,"期間",null,null,null,"年"]
["離婚歴(※)",null,null,"あり",null,null,"（再婚歴",null,null,"有","無","）","なし",null,null,null,null,4,null,null,null,null,null,null,"期間",null,null,null,"年"]
["最終学歴",null,null,null,null,null,null,null,null,null,null,"卒業",null,"中退",null,null,null,5,null,null,null,null,null,null,"期間",null,null,null,"年"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"仕事をやめたのは",null,null,null,null,null,null,null,"歳"]
[]
["来院目的\n（※）",null,null,"外来通院",null,null,null,"（","精神科・物忘れ外来・内科",null,null,null,null,null,null,null,null,"）",null,null,"入院相談"]
[null,null,null,"老健入所相談",null,null,null,null,null,null,"老健短期入所（ショートステイ）相談"]
[]
["今までにかかったことのある怪我や病気について"]
[]
[null,"病名",null,null,null,null,null,null,null,null,null,null,"年齢・いつ頃か",null,null,null,null,null,null,null,"医療機関名"]
[]
[]
[]
[]
[null,"かかりつけ医はいますか？",null,null,null,null,null,null,null,null,null,null,"いない",null,null,"いる",null,null,"医療機関"]
[null,"意識を失ったことはありますか？",null,null,null,null,null,null,null,null,null,null,"ない",null,null,"ある",null,null,"時期"]
[null,"身体が傾いたり、\n身体のマヒが出たことはありますか？",null,null,null,null,null,null,null,null,null,null,"ない",null,null,"ある",null,null,"時期"]
[null,"頭のCTやMRIの検査を受けたことは\nありますか？",null,null,null,null,null,null,null,null,null,null,"ない",null,null,"ある",null,null,"時期"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医療機関"]
[null,"床ずれができたことはありますか？",null,null,null,null,null,null,null,null,null,null,"ない",null,null,"ある",null,null,"時期"]
[null,"食べ物に対するアレルギーは\nありますか？",null,null,null,null,null,null,null,null,null,null,"ない",null,null,"ある",null,null,"食品名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"症状"]
[null,"くすりに対するアレルギーは\nありますか？",null,null,null,null,null,null,null,null,null,null,"ない",null,null,"ある",null,null,"薬品名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"症状"]
[null,"お酒は飲みますか？",null,null,null,null,null,null,null,null,null,null,"飲まない",null,null,"飲む",null,null,"頻度",null,"週",null,"回","飲む量"]
[null,"タバコは吸いますか？",null,null,null,null,null,null,null,null,null,null,"吸わない",null,null,"吸う",null,null,"1日の本数",null,null,null,null,null,"本"]
[]
[]
["現在の病気、または受診の目的について"]
[]
[null," 物忘れにはいつ頃気づきましたか？"]
[]
[]
[null,"現在、最も困っていることは何ですか？"]
[]
[]
[]
[null," その時、何かきっかけがありましたか？ありましたら具体的に書いて下さい。"]
[]
[]
[null,"そのことで、今までに病院にかかった事はありますか？（※）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"いいえ",null,null,"はい（下記も記入して下さい）"]
[]
[null,"受診日（年・月）",null,null,null,null,null,"医療機関名",null,null,null,null,null,null,"病名や治療について、どの様な説明を受けましたか？"]
[]
[]
[]
[null,"天王病院をどのようにして知りましたか？（※）"]
[null,"ﾎｰﾑﾍﾟｰｼﾞ",null,null,null,"看板",null,null,"ご紹介を受けて",null,null,null,null,"（","ご家族",null,null,"ご友人",null,null,"病院",null,"施設",null,"ｹｱﾏﾈｰｼﾞｬｰ",null,null,"）"]
[null,"パンフレット",null,null,null,"その他",null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[]
["【身体機能アンケート】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"患者氏名",null,null,{"$f":"IF(B5=\"\",\"\",B5)","v":""}]
[]
[]
["食事介助",null,null,null,"全介助",null,null,null,null,"ほとんど介助",null,null,null,null,"半介助",null,null,null,null,"自分でするが\n遅い",null,null,null,null,"自立"]
["食種",null,"主食",null,"ごはん",null,null,null,null,"お粥",null,null,null,null,"流動食",null,null,null,null,"経管\n栄養",null,"鼻腔",null,null,null,"点滴中"]
[null,null,"副食",null,"常菜",null,null,null,null,"キザミ",null,null,null,null,"ミキサー",null,null,null,null,null,null,"胃ろう"]
["飲込み(固形)",null,null,null,"できない",null,null,null,null,"むせる",null,null,null,null,"時々むせる",null,null,null,null,"たまにむせる",null,null,null,null,"食べられる"]
["飲込み(汁物)",null,null,null,"できない",null,null,null,null,"むせる",null,null,null,null,"時々むせる",null,null,null,null,"たまにむせる",null,null,null,null,"食べられる"]
["排泄（大便）",null,null,null,"常時おむつ\n又はストマ",null,null,null,null,"介助を要する\n（夜間はオムツ）",null,null,null,null,"半介助\n（便器使用）",null,null,null,null,"トイレに行くが\n時々もらす",null,null,null,null,"自立"]
["排泄（小便）",null,null,null,"常時おむつ\n又はバルーン",null,null,null,null,"介助を要する\n（夜間はオムツ）",null,null,null,null,"半介助\n（便器使用）",null,null,null,null,"トイレに行くが\n時々もらす",null,null,null,null,"自立"]
["起立",null,null,null,"できない",null,null,null,null,"かなりの介助\nつかまり立ち",null,null,null,null,"辛うじて可能",null,null,null,null,"できるが遅い",null,null,null,null,"自立"]
["歩行",null,null,null,"できない",null,null,null,null,"かなりの介助\n這う・いざる",null,null,null,null,"辛うじて可能",null,null,null,null,"できるが遅い",null,null,null,null,"自立"]
["行動範囲",null,null,null,"ベッド上",null,null,null,null,"居室に限る",null,null,null,null,"自宅の庭\n介助で外出",null,null,null,null,"散歩程度なら\n可能",null,null,null,null,"自立"]
["入浴",null,null,null,"できない",null,null,null,null,"ほとんど介助",null,null,null,null,"辛うじて可能\n又は見守り",null,null,null,null,"できるが遅い",null,null,null,null,"自立"]
["更衣",null,null,null,"できない",null,null,null,null,"ほとんど介助",null,null,null,null,"辛うじて可能\n又は見守り",null,null,null,null,"できるが遅い",null,null,null,null,"自立"]
["口腔ケア",null,null,null,"できない",null,null,null,null,"ほとんど介助",null,null,null,null,"自立"]
["入れ歯",null,null,null,"なし",null,null,null,null,"あり　⇒",null,null,null,null,"（","上",null,"下",null,"部分入れ歯",null,null,null,"）"]
["身の回りの\n整理",null,null,null,"できない",null,null,null,null,"ほとんど介助",null,null,null,null,"辛うじて可能\n又は見守り",null,null,null,null,"できるが遅い",null,null,null,null,"自立"]
["聴力",null,null,null,"全く聞こえない",null,null,null,null,"大きな声又は\n補聴器を使用",null,null,null,null,"やや大きな声",null,null,null,null,"大体聞こえる\nが、不十分",null,null,null,null,"正常"]
["視力",null,null,null,"全く見えない",null,null,null,null,"顔の輪郭が\nわかるくらい",null,null,null,null,"大きな活字が\nやっと見える",null,null,null,null,"ややかすむ",null,null,null,null,"正常"]
["意思表示",null,null,null,"できない",null,null,null,null,"基本的な\n要求のみ",null,null,null,null,"辛うじて可能",null,null,null,null,"大体できるが\n不完全",null,null,null,null,"正常"]
["話の理解",null,null,null,"できない",null,null,null,null,"稀に了解する",null,null,null,null,"辛うじて可能",null,null,null,null,"大体できるが\n不完全",null,null,null,null,"正常"]
["睡眠",null,null,null,"夜眠れない\n(昼も起きている)",null,null,null,null,"夜眠れない\n(昼に寝ている)",null,null,null,null,"短時間眠る",null,null,null,null,"薬を飲んだら\n眠れる",null,null,null,null,"よく眠れる"]
["特記事項"]