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[null,"ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入日"]
[null,"名前",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入者"]
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[null,"生年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"延命治療希望",null,null,null,null,null,"あり",null,null,null,"なし",null,null,null,"わからない"]
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[null,"アレルギー（食物）",null,null,null,null,null,null,null,"なし",null,null,null,"わからない",null,null,null,null,null,"障害　",null,null,null,null,null,"障害なし",null,null,null,null,null,null,null,"わからない"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"身体(視覚・聴覚・音声言語), 知的（軽度・中等度・重度）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発達",null,null,null,null,null,null,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,"精神"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護認定：支援 □1 □2 要介護 □1 □2 □3 □4 □5"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"寝たきり度　　 　：自立・J1・J2・A1・A2・B1・B2・C1・C2"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"日常生活自立度：自立・Ⅰ・Ⅱa・Ⅱb・Ⅲa・Ⅲb・Ⅳ・M"]
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[null,"アレルギー（医薬品）",null,null,null,null,null,null,null,"なし",null,null,null,null,null,null,null,null,null,"特記事項"]
[null,null,"造影剤",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ペースメーカー、ICD挿入",null,null,null,null,null,null,null,null,null,"在宅酸素療法"]
[null,null,"薬：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"透析",null,null,null,null,null,null,null,null,null,"CPAP"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"手術歴：虫垂炎"]
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[null,"今使用している薬",null,null,null,null,null,null,null,null,null,"使用中の薬なし",null,null,null,null,null,null,null,null,"わからない"]
[null,null,"抗血小板剤",null,null,null,null,null,null,null,null,"利胆剤",null,null,null,null,null,null,null,null,"血管収縮剤",null,null,null,null,null,null,null,"カルシウム剤"]
[null,null,"抗凝固剤",null,"抗凝固剤","抗凝固剤","抗凝固剤","抗凝固剤","抗凝固剤","抗凝固剤",null,"催眠鎮静剤","催眠鎮静剤","催眠鎮静剤","催眠鎮静剤","催眠鎮静剤","催眠鎮静剤","催眠鎮静剤","催眠鎮静剤",null,"血管拡張剤","血管拡張剤","血管拡張剤","血管拡張剤","血管拡張剤","血管拡張剤","血管拡張剤",null,"抗ヒスタミン剤"]
[null,null,"血糖降下剤",null,"血糖降下剤","血糖降下剤","血糖降下剤","血糖降下剤","血糖降下剤","血糖降下剤",null,"抗不安剤","抗不安剤","抗不安剤","抗不安剤","抗不安剤","抗不安剤","抗不安剤","抗不安剤",null,"高脂血症用剤","高脂血症用剤","高脂血症用剤","高脂血症用剤","高脂血症用剤","高脂血症用剤","高脂血症用剤",null,"ステロイド剤",null,"ステロイド剤","ステロイド剤","ステロイド剤","ステロイド剤","ステロイド剤","ステロイド剤","ステロイド剤","ステロイド剤"]
[null,null,"インスリン",null,"インスリン","インスリン","インスリン","インスリン","インスリン","インスリン",null,"抗てんかん剤","抗てんかん剤","抗てんかん剤","抗てんかん剤","抗てんかん剤","抗てんかん剤","抗てんかん剤","抗てんかん剤",null,"気管支拡張剤","気管支拡張剤","気管支拡張剤","気管支拡張剤","気管支拡張剤","気管支拡張剤","気管支拡張剤",null,"甲状腺，副甲状腺ホルモン剤",null,"甲状腺，副甲状腺ホルモン剤","甲状腺，副甲状腺ホルモン剤","甲状腺，副甲状腺ホルモン剤","甲状腺，副甲状腺ホルモン剤","甲状腺，副甲状腺ホルモン剤","甲状腺，副甲状腺ホルモン剤","甲状腺，副甲状腺ホルモン剤","甲状腺，副甲状腺ホルモン剤"]
[null,null,"強心剤",null,"強心剤","強心剤","強心剤","強心剤","強心剤","強心剤",null,"解熱鎮痛消炎剤","解熱鎮痛消炎剤","解熱鎮痛消炎剤","解熱鎮痛消炎剤","解熱鎮痛消炎剤","解熱鎮痛消炎剤","解熱鎮痛消炎剤","解熱鎮痛消炎剤",null,"吐しゃ剤，整腸剤","吐しゃ剤，整腸剤","吐しゃ剤，整腸剤","吐しゃ剤，整腸剤","吐しゃ剤，整腸剤","吐しゃ剤，整腸剤","吐しゃ剤，整腸剤",null,"その他のホルモン剤",null,"その他のホルモン剤","その他のホルモン剤","その他のホルモン剤","その他のホルモン剤","その他のホルモン剤","その他のホルモン剤","その他のホルモン剤","その他のホルモン剤"]
[null,null,"不整脈用剤",null,"不整脈用剤","不整脈用剤","不整脈用剤","不整脈用剤","不整脈用剤","不整脈用剤",null,"抗パーキンソン剤","抗パーキンソン剤","抗パーキンソン剤","抗パーキンソン剤","抗パーキンソン剤","抗パーキンソン剤","抗パーキンソン剤","抗パーキンソン剤",null,"消化性潰瘍用剤","消化性潰瘍用剤","消化性潰瘍用剤","消化性潰瘍用剤","消化性潰瘍用剤","消化性潰瘍用剤","消化性潰瘍用剤",null,"抗悪性腫瘍剤",null,"抗悪性腫瘍剤","抗悪性腫瘍剤","抗悪性腫瘍剤","抗悪性腫瘍剤","抗悪性腫瘍剤","抗悪性腫瘍剤","抗悪性腫瘍剤","抗悪性腫瘍剤"]
[null,null,"利尿剤",null,"利尿剤","利尿剤","利尿剤","利尿剤","利尿剤","利尿剤",null,"精神神経用剤","精神神経用剤","精神神経用剤","精神神経用剤","精神神経用剤","精神神経用剤","精神神経用剤","精神神経用剤",null,"制酸剤","制酸剤","制酸剤","制酸剤","制酸剤","制酸剤","制酸剤",null,"免疫抑制剤",null,"免疫抑制剤","免疫抑制剤","免疫抑制剤","免疫抑制剤","免疫抑制剤","免疫抑制剤","免疫抑制剤","免疫抑制剤"]
[null,null,"血圧降下剤",null,"血圧降下剤","血圧降下剤","血圧降下剤","血圧降下剤","血圧降下剤","血圧降下剤",null,"泌尿器官用剤","泌尿器官用剤","泌尿器官用剤","泌尿器官用剤","泌尿器官用剤","泌尿器官用剤","泌尿器官用剤","泌尿器官用剤",null,"下剤","下痢","下痢","下痢","下痢","下痢","下痢",null,"その他",null,"その他(　　　　　　　　　　　　　)","その他(　　　　　　　　　　　　　)","その他(　　　　　　　　　　　　　)","その他(　　　　　　　　　　　　　)","その他(　　　　　　　　　　　　　)","その他(　　　　　　　　　　　　　)","その他(　　　　　　　　　　　　　)","その他(　　　　　　　　　　　　　)"]
[]
[null,"内服薬記入欄："]
[]
[]
[]
[null,"既往歴（治療中の病気を含む）",null,null,null,null,null,null,null,null,null,null,null,"既往歴なし",null,null,null,null,null,null,"　　わからない",null,null,null,null,"＊記入方法：☑既往歴　〇現病歴"]
[null,"脳・神経・感覚器・精神の病気"]
[null,null,"脳出血",null,null,null,null,null,null,null,null,"緑内障",null,null,null,null,null,null,null,null,"動脈瘤",null,null,null,null,null,null,null,"統合失調病"]
[null,null,"脳梗塞",null,null,null,null,null,null,null,null,"白内障",null,null,null,null,null,null,null,null,"てんかん",null,null,null,null,null,null,null,"慢性アルコール中毒"]
[null,null,"くも膜下出血",null,null,null,null,null,null,null,null,"うつ病",null,null,null,null,null,null,null,null,"パーキンソン病",null,null,null,null,null,null,null,"その他："]
[null,"心臓・血管・血圧の病気"]
[null,null,"高血圧",null,null,null,null,null,null,null,null,"動脈の疾患",null,null,null,null,null,null,null,null,"狭心病",null,null,null,null,null,null,null,"深部静脈血栓病"]
[null,null,"不整脈",null,null,null,null,null,null,null,null,"動脈瘤",null,null,null,null,null,null,null,null,"心筋梗塞",null,null,null,null,null,null,null,"その他："]
[null,"肺・気管支・消化器の病気"]
[null,null,"喘息",null,null,null,null,null,null,null,null,"肺塞栓",null,null,null,null,null,null,null,null,"肺結核",null,null,null,null,null,null,null,"COPD(慢性閉塞性肺疾患)"]
[null,null,"慢性気管支炎",null,null,null,null,null,null,null,null,"肺気腫",null,null,null,null,null,null,null,null,"肝機能障害",null,null,null,null,null,null,null,"その他："]
[null,null,"胃・十二指腸潰瘍",null,null,null,null,null,null,null,null,"肝硬変",null,null,null,null,null,null,null,null,"肝炎（B型、C型）"]
[null,null,"炎症性腸疾患",null,null,null,null,null,null,null,null,"胆石",null,null,null,null,null,null,null,null,"膵炎"]
[null,"腎・泌尿器・代謝異常・免疫異常の病気"]
[null,null,"慢性腎臓病",null,null,null,null,null,null,null,null,"尿路結石",null,null,null,null,null,null,null,null,"腎不全",null,null,null,null,null,null,null,"ネフローゼ"]
[null,null,"腎炎",null,null,null,null,null,null,null,null,"前立腺肥大",null,null,null,null,null,null,null,null,"脂質異常",null,null,null,null,null,null,null,"リウマチ"]
[null,null,"糖尿病",null,null,null,null,null,null,null,null,"甲状腺機能低下症",null,null,null,null,null,null,null,null,"痛風",null,null,null,null,null,null,null,"甲状腺機能亢進症"]
[]
[null,"既往歴記入欄（上記以外・がん含む）\n\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"現病歴記入欄（上記以外・がん含む）\n"]