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{"sheet":"Sheet1","index":0,"n_rows":37,"n_cols":12,"rows_kept":37,"cut":false,"hidden":false,"merged":[[2,1,4,1],[6,10,6,11],[7,10,7,11],[9,2,9,5],[32,1,32,12],[2,6,2,11],[2,3,2,5],[7,2,7,7],[6,2,6,7],[3,2,4,11],[6,8,6,9],[7,8,7,9],[20,5,20,7],[25,6,25,11],[5,8,5,11],[5,3,5,6],[17,6,17,11],[19,6,19,11],[21,1,21,11]]}
[null,"森整形外科リハビリクリニック　問診票"]
[null,"　　　　　　　　　　（わかる範囲で結構ですのでご記入ください）"]
[null,"現住所","〒","-"]
[]
[]
[null,"電話番号","自宅","　    -      -",null,null,null,"携帯","   - 　     -"]
[null,"ふりがな",null,null,null,null,null,null,"身長",null,"体重"]
[null,"氏名",null,null,null,null,null,null,"cm",null,"kg"]
[null,"１．今回の症状は　いつ頃からお困りですか？"]
[null,null,"(                    )",null,null,null,"頃から"]
[null,"２．原因に心当たりはありますか？"]
[null,null,null,"特になし",null,"交通事故",null,"転倒転落",null,"運動",null,"労働災害"]
[null,null,null,"その他　（　　　　　　　　　　　　　　　　　　　）"]
[null,"３．どのような症状ですか？"]
[null,"症状のある場所：",null,null,"(   　　　　　　        )"]
[null,"症状の内容：",null,null,null,"痛い",null,"しびれる",null,"腫れている",null,"その他"]
[null,"４．今回の症状で治療を受けたことがありますか？"]
[null,null,null,"いいえ",null,"はい","治療内容（　　　　　　　　　　　　）"]
[null,"５．現在内服している薬はありますか？"]
[null,null,null,"いいえ",null,"はい","内容（　　　　　　　　　　　　　　）"]
[null,null,null,null,null,"お薬手帳はありますか",null,null,null,"あり",null,"なし"]
[null,"６．今までに下記の病気にかかったことはありますか？（あるものに☑）"]
[null,null,null,"高血圧",null,"糖尿病",null,"脳梗塞",null,"心臓病"]
[null,null,null,"腎臓病",null,"胃潰瘍",null,"緑内障"]
[null,"７．薬や食べ物のアレルギーはありますか？"]
[null,null,null,"いいえ",null,"はい","（内容　　　　　　　　　　　　　　）"]
[null,"８．女性の方のみお答えください。妊娠中もしくはその可能性、また授乳中ですか？"]
[null,null,null,"いいえ",null,"はい",null,"妊娠の可能性あり",null,null,null,"授乳中"]
[null,"９．希望する検査・治療はありますか？"]
[null,null,null,"骨密度測定",null,null,null,"リハビリ"]
[null,"10．介護保険をお持ちですか？"]
[null,null,null,"はい","( 等級　　　　　　　　）",null,null,null,null,"いいえ"]
[null,"１１．当院を何で知りましたか？"]
[null,null,null,"口コミ",null,"インターネット",null,null,null,"前を通って"]
[null,null,null,"他院からの紹介",null,null,null,"人からの紹介（紹介者　　　　　　　　　　　　）"]
[null,"ありがとうございました。受付までお持ちください。"]
[null,"なお、出血をともなう傷がある場合は受付にお申し出ください。"]