{"text_format":"1","workbook":"xlsx","n_sheets":2,"sheets":["意見書　１枚目","意見書　２枚目"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":2,"comments":1,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"意見書　１枚目","index":0,"n_rows":109,"n_cols":201,"rows_kept":109,"cut":false,"hidden":false,"merged":[[1,15,1,50],[1,59,1,119],[1,126,1,138],[1,144,1,168],[3,85,3,92],[3,99,3,107],[3,113,3,122],[84,156,84,159],[84,110,84,113],[82,140,82,143],[44,103,44,185],[50,122,50,125],[32,2,34,34],[43,101,43,121],[43,13,43,97],[58,3,62,198],[53,7,53,197],[50,99,50,102],[21,155,21,194],[25,75,25,80],[37,2,39,45],[64,2,66,106],[9,24,9,91],[15,4,16,138],[84,95,84,98],[68,95,68,98],[28,55,28,58],[25,48,25,57],[25,37,25,47],[25,81,25,90],[25,92,25,97],[33,78,33,81],[35,78,35,81],[33,97,33,100],[46,13,46,98],[12,153,12,171],[12,138,12,149],[21,5,21,32],[72,33,72,36],[108,127,108,130],[100,91,101,91],[108,141,108,167],[108,179,108,182],[106,47,106,196],[25,59,25,64],[43,124,43,136],[93,171,93,174],[45,168,45,175],[68,33,68,36],[68,64,68,67],[52,7,52,197],[47,139,47,147],[47,137,47,138],[89,64,89,67],[47,101,47,121],[13,71,13,73],[13,45,13,47],[19,146,19,153],[19,155,19,194],[3,166,3,174],[3,180,3,189],[18,33,18,119],[20,33,20,119],[17,33,17,119],[19,33,19,119],[3,152,3,159],[15,141,16,144],[15,173,16,196],[15,168,16,171],[15,146,16,166],[6,109,7,131],[5,21,7,34],[12,135,12,137],[12,118,12,134],[6,36,7,91],[17,5,17,32],[19,5,19,32],[13,96,13,98],[12,150,12,152],[12,86,12,93],[12,104,12,117],[12,28,12,34],[9,105,9,197],[114,196,114,200],[98,174,98,177],[106,7,106,10],[106,21,106,24],[98,21,98,24],[100,64,101,67],[100,145,101,148],[100,87,101,90],[98,87,98,90],[98,38,98,41],[100,38,101,41],[100,110,101,113],[98,145,98,148],[100,43,101,62],[100,69,101,85],[100,197,101,198],[100,92,101,108],[98,7,98,10],[93,64,93,67],[91,64,91,67],[82,171,82,174],[82,110,82,113],[82,156,82,159],[47,13,47,97],[47,154,47,162],[91,171,91,174],[91,95,91,98],[48,104,48,185],[47,122,47,123],[50,104,50,114],[93,95,93,98],[91,125,91,128],[93,125,93,128],[50,77,50,80],[70,33,70,36],[82,125,82,128],[84,64,84,67],[89,95,89,98],[47,168,47,175],[70,64,70,67],[84,80,84,83],[82,95,82,98],[28,39,28,42],[47,124,47,136],[46,103,46,185],[35,44,35,47],[35,63,35,66],[33,63,33,66],[43,168,43,175],[100,161,101,196],[84,125,84,128],[100,114,101,114],[100,149,101,149],[100,150,101,159],[100,42,101,42],[100,68,101,68],[84,140,84,143],[84,171,84,174],[98,64,98,67],[82,187,82,190],[82,64,82,67],[70,95,70,98],[76,2,78,51],[98,110,98,113],[98,127,98,130],[100,115,101,143],[31,55,31,58],[45,101,45,121],[43,154,43,162],[42,13,42,97],[44,13,44,98],[33,112,33,115],[33,134,33,137],[35,134,35,137],[33,159,33,162],[45,13,45,97],[45,122,45,123],[45,124,45,136],[45,139,45,147],[35,159,35,162],[45,137,45,138],[45,154,45,162],[35,103,35,106],[43,137,43,138],[33,178,33,181],[9,96,9,100],[84,3,84,61],[13,58,13,60],[82,80,82,83],[68,125,68,128],[68,156,68,159],[21,33,21,119],[82,3,82,61],[70,125,70,128],[74,33,74,36],[21,146,21,153],[72,125,72,128],[5,2,13,20],[6,94,7,101],[12,39,12,46],[12,52,12,59],[12,65,12,72],[6,103,7,106],[35,178,35,194],[43,122,43,123],[43,139,43,147],[25,65,25,73],[31,39,31,42]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険者番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"０７２０１７",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"０４",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"０００１"]
[]
[null,null,"主治医意見書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（申請日",null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"日）",null,null,null,null,null,null,null,null,"記入日",null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"日"]
[]
[null,null,"申請者",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（ふりがな）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",null,null,null,null,null,null,null,null,"〒"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,null,null,null,"福島市"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,null,null,null,null,null,null,null,"日生",null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"歳）",null,null,null,"連絡先",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
[]
[null,null,null,null,"上記の申請者に関する意見は以下の通りです。主治医として本意見書が、介護サービス計画作成等に利用されることに",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,"同意する",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,"同意しない"]
[]
[null,null,null,null,null,"医師氏名"]
[]
[null,null,null,null,null,"医療機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話"]
[]
[null,null,null,null,null,"医療機関所在地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX"]
[]
[]
[]
[null,null,"(1)最終診察日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"日"]
[]
[]
[null,null,"(2)意見書作成回数",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,"初回",null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,"２回目以上"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,null,"有",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2]
[null,null,"(3)他科受診の有無"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(有の場合) →",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,"内科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"精神科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"外科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"整形外科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"脳神経外科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"皮膚科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"泌尿器科"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"婦人科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"眼科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"耳鼻咽喉科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ﾘﾊﾋﾞﾘﾃｰｼｮﾝ科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"歯科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,false]
[]
[null,null,"１．傷病に関する意見"]
[]
[]
[]
[null,null,"(1)診断名(特定疾病または生活機能低下の直接の原因となっている傷病名については１．に記入)及び発症年月日"]
[]
[null,null,null,null,null,"１．",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発症年月日　（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,null,null,null,null,null,null,null,"日頃）"]
[]
[null,null,null,null,null,"２．",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発症年月日　（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,null,null,null,null,null,null,null,"日頃）"]
[]
[null,null,null,null,null,"３．",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"発症年月日　（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,null,null,null,null,null,null,null,null,null,null,null,"日頃）"]
[]
[]
[null,null,"(2)症状としての安定性",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,"安定",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"不安定",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"不明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[]
[null,null,null,null,null,null,null,"(「不安定」とした場合、具体的な状況を記入)"]
[]
[]
[null,null,"(3)生活機能低下の直接の原因となっている傷病または特定疾病の経過及び投薬内容を含む治療内容"]
[null,null,null,null,null,null,"(最近(概ね６ヶ月以内)介護に影響のあったもの 及び 特定疾病についてはその診断の根拠等について記入)"]
[]
[]
[]
[]
[]
[]
[]
[null,null,"２．特別な医療(過去１４日間以内に受けた医療のすべてにチェック)"]
[]
[]
[]
[null,null,null,"処置内容",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"点滴の管理",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"中心静脈栄養",null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ストーマの処置",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"酸素療法"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"レスピレーター",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"気管切開の処置",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"疼痛の看護",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"経管栄養"]
[]
[null,null,null,"特別な対応",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"モニター測定(血圧、心拍、酸素飽和度等)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"褥瘡の処置"]
[]
[null,null,null,"失禁への対応",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"カテーテル(コンドームカテーテル、留置カテーテル等)"]
[]
[null,null,"３．心身の状態に関する意見"]
[]
[]
[]
[null,null,"(1)日常生活の自立度等について"]
[]
[null,null,null,"・障害高齢者の日常生活自立度(寝たきり度)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｊ１",null,null,null,null,null,null,null,null,null,null,null,null,null,"　","Ｊ２",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ａ１",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ａ２",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｂ１",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｂ２",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｃ１",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｃ２"]
[]
[null,null,null,"・認知症高齢者の日常生活自立度",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｉ",null,null,null,null,null,null,null,null,null,null,null,null,"　","Ⅱａ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ⅱｂ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ⅲａ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ⅲｂ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ⅳ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｍ"]
[]
[]
[null,null,"(2)認知症の中核症状(認知症以外の疾患で同様の症状を認める場合を含む)"]
[]
[null,null,null,null,"・短期記憶",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"問題なし",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"問題あり"]
[]
[null,null,null,null,"・日常の意思決定を行うための認知能力",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"いくらか困難",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"見守りが必要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"判断できない"]
[]
[null,null,null,null,"・自分の意思の伝達能力",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"伝えられる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"いくらか困難",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"具体的要求に限られる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"伝えられない"]
[]
[]
[null,null,"(3)認知症の行動・心理症状(BPSD)　(該当する項目全てチェック：認知症以外の疾患で同様の症状を認める場合を含む)"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"幻視・幻聴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"妄想",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　",null,null,null,null,"昼夜逆転",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"暴言",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"暴行",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護への抵抗",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"徘徊",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"火の不始末",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"不潔行為",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"異食行動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性的問題行動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")",null,null,false]
[]
[]
[]
[null,null,"(4)その他の精神・神経症状の有無"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,null,null,null,"[症状名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〔専門医受診の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無〕",null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]

{"sheet":"意見書　２枚目","index":1,"n_rows":91,"n_cols":202,"rows_kept":91,"cut":false,"hidden":false,"merged":[[19,141,19,144],[19,152,19,155],[21,130,21,133],[27,8,27,11],[23,8,23,11],[25,130,25,133],[25,141,25,144],[25,152,25,155],[17,8,17,11],[20,56,20,112],[27,152,27,155],[21,8,21,11],[27,130,27,133],[21,56,21,113],[25,55,25,113],[24,55,24,113],[26,55,26,113],[23,63,23,66],[19,130,19,133],[19,56,19,113],[19,8,19,11],[62,10,62,13],[62,57,62,60],[62,104,62,107],[67,136,67,139],[78,72,78,75],[53,184,53,187],[71,171,71,173],[67,57,67,60],[67,96,67,99],[55,138,55,141],[53,86,53,89],[53,106,53,109],[55,10,55,13],[55,27,55,30],[55,65,55,68],[55,86,55,89],[53,52,53,55],[57,26,57,184],[71,57,71,60],[56,31,56,185],[53,161,53,164],[69,10,69,13],[78,137,78,140],[78,159,78,194],[23,166,23,169],[21,141,21,144],[21,152,21,155],[55,106,55,109],[55,156,55,184],[27,141,27,144],[29,2,31,77],[23,76,23,79],[37,150,37,153],[39,150,39,153],[23,178,23,181],[44,41,44,44],[39,67,39,70],[39,98,39,101],[44,121,44,124],[48,48,48,190],[35,67,35,70],[37,98,37,101],[35,98,35,101],[27,55,27,113],[23,113,23,116],[23,125,23,128],[25,8,25,11],[90,2,92,199],[80,159,80,194],[80,72,80,75],[80,91,80,126],[80,137,80,140],[71,174,71,193],[86,46,86,127],[86,15,86,18],[86,31,86,34],[86,137,86,140],[82,10,82,13],[99,196,99,200],[71,136,71,139],[77,62,77,88],[71,96,71,99],[78,10,78,13],[46,121,46,124],[35,150,35,153],[37,67,37,70],[46,41,46,44],[53,138,53,141],[69,57,69,60],[69,96,69,99],[69,136,69,139],[78,29,78,64],[78,91,78,126],[53,10,53,13],[53,27,53,30],[67,10,67,13],[88,2,89,57],[94,3,94,198],[80,10,80,13],[80,29,80,64],[71,10,71,13],[73,10,73,13],[15,40,15,43],[15,130,15,133],[15,141,15,144],[17,141,17,144],[17,152,17,155],[13,86,13,89],[13,99,13,102],[13,120,13,123],[18,56,18,112],[15,152,15,155],[17,130,17,133],[17,56,17,113],[15,72,15,113],[13,179,13,182],[11,73,11,76],[13,73,13,76],[13,153,13,156],[1,16,1,51],[1,61,1,120],[1,127,1,137],[1,144,1,167],[6,32,6,35],[13,40,13,43],[6,94,6,106],[9,55,9,116],[11,153,11,156],[11,166,11,169],[13,166,13,169],[11,120,11,123],[11,99,11,102],[9,117,9,119],[6,183,6,186],[9,8,9,11],[11,8,11,11],[11,40,11,43],[11,86,11,89],[6,58,6,71],[6,153,6,156],[6,169,6,172],[6,22,6,25],[11,179,11,182]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保険者番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"被保険者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"０７２０１７",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"'意見書　１枚目'!$BH$2","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"０４",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"０００２"]
[]
[]
[null,null,null,null,"（5）　身体の状態"]
[]
[null,null,null,null,null,null,null,"利き腕",null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"右",null,null,null,null,null,null,null,null,null,"左",null,null,null,null,"）",null,null,null,"身長＝",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"cm",null,null,null,null,null,"体重＝",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"kg",null,null,null,null,"(過去6ヵ月の体重の変化",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"増加",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"維持",null,null,null,null,null,null,null,null,null,null,null,null,null,"減少）"]
[]
[]
[null,null,null,null,null,null,null,null,"　",null,null,null,null,"四肢欠損",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（部位 :　　　　　　　　　　　　　　　　　　　　　　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"麻痺",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右上肢 （程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左上肢 （程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右下肢 （程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左下肢 （程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他　（部位：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"筋力の低下",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（部位：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"関節の拘縮",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（部位：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"関節の痛み",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（部位：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"失調・不随意運動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・上　肢",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右",null,null,null,null,null,null,null,null,null,null,null,null,"左",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・下　肢",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右",null,null,null,null,null,null,null,null,null,null,null,"左",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・体　幹",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右",null,null,null,null,null,null,null,null,null,null,null,"左",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"褥瘡",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（部位：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"その他の皮膚疾患",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（部位：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"程度：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"軽",null,null,null,null,null,null,null,null,null,null,"中",null,null,null,null,null,null,null,null,null,null,"重）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,"4. 生活機能とサービスに関する意見"]
[]
[]
[]
[null,null,null,null,"（1）　移動"]
[]
[null,null,null,null,null,null,null,null,null,null,"屋外歩行",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介助があればしている",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"していない"]
[]
[null,null,null,null,null,null,null,null,null,null,"車いすの使用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"用いていない",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主に自分で操作している",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主に他人が操作している"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null,null,null,"歩行補助具・装具の使用（複数選択可）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"用いていない",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"屋外で使用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"屋内で使用"]
[]
[]
[null,null,null,null,"（2）　栄養・食生活"]
[]
[null,null,null,null,null,null,null,null,null,null,"食事行為",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"自立ないし何とか自分で食べられる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"全面介助"]
[]
[null,null,null,null,null,null,null,null,null,null,"現在の栄養状態",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"良好",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"不良"]
[]
[null,null,null,null,"→",null,null,null,null,null,"栄養・食生活上の留意点",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[null,null,null,null,"（3）　現在あるかまたは今後発生の可能性の高い状態とその対処方針"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"尿失禁",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"転倒・骨折",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"移動能力の低下",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"褥瘡",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"心肺機能の低下",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"閉じこもり",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"意欲低下",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"徘徊"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"低栄養",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"摂食・嚥下機能低下",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"脱水",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"易感染性",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"がん等による疼痛",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,null,null,null,"→　対処方針（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[null,null,null,null,"（4）　サービス利用による生活機能の維持・改善の見通し"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"期待できる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"期待できない",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"不明"]
[]
[]
[null,null,null,null,"（5）　医学的管理の必要性　（特に必要性の高いものには下線を引いて下さい。　予防給付により提供されるサービスを含みます。）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"訪問診療",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"訪問看護",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"訪問歯科診療",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"訪問薬剤管理指導"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"訪問リハビリテーション",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"短期入所療養介護",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"訪問歯科衛生指導",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"訪問栄養食事指導"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"通所リハビリテーション",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"老人保健施設",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"介護医療院",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他の医療系サービス",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")",null,null,null,null,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"特記すべき事項なし"]
[]
[]
[null,null,null,null,"（6）　サービス提供時における医学的観点からの留意事項（該当するものを選択するとともに、具体的に記載）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"血圧",null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,null,null,null,null,null,"摂食",null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"嚥下",null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,false,false]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"移動",null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,null,null,null,null,null,"運動",null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,false,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"特記すべき事項なし"]
[]
[null,null,null,null,"（7）　感染症の有無　（有の場合は具体的に記入して下さい。）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"有（　　　　　　　　　　　　　　　　　　　            　　　　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,null,null,null,null,null,null,null,"不明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,3]
[]
[null,null,"5.特記すべき事項"]
[]
[null,null,"　要介護認定及び介護サービス計画作成時に必要な医学的なご意見等を見守りに影響を及ぼす疾病の状況等の留意点を含め記載して下さい。特に、介護に要する手間に影響を及ぼす事項について記載して下さい。なお、専門医等に別途意見を求めた場合はその内容、結果も記載して下さい。（情報提供書や障害者手帳の申請に用いる診断書等の写しを添付して頂いても結構です。）"]