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[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"↑前橋赤十字病院薬剤部FAX：027-225-5258\nFAXの流れ：保険薬局 → 薬剤部外来担当薬剤師 → 処方医師"]
["がん化学療法トレーシングレポート （服薬情報提供書）　（抗がん剤治療用）",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,"報告日",null,null,null,null,"年",null,null,"月",null,null,"日"]
[]
["病院名",null,null,"前橋赤十字",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"病院",null,null,null,null,"　保険薬局　名称　所在"]
[]
["処方医",null,null,null,null,null,null,null,null,null,null,null,"科",null,null,null,null,null,null,null,null,null,"先生",null,null,null,null,"電 話 番 号　："]
["患者ID　：",null,null,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番号　："]
["生年月日：",null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,null,"日",null,null,null,null,null,null,null,"担当薬剤師名："]
["この情報を伝えることに対して患者の同意を",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"得た",null,null,null,"得ていない",null,null,null,null,"聞き取り日",null,null,null,null,"：",null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"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,"聞き取り方法",null,null,null,null,"：",null,"来局時",null,null,null,"電話",null,null,"その他（",null,null,null,null,null,null,null,"）"]
[null,null,"患者は主治医への報告を拒否していますが、治療上重要だと思われますので報告いたします",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"前回治療日",null,null,null,null,"：",null,null,null,"年",null,null,"月",null,null,"日",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,"レジメン名",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,"ICI併用",null,null,null,"あり又は投与歴あり（　　　　年　　月）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"不明"]
["服薬状況",null,null,null,null,null,"問題なし",null,null,null,null,null,"問題あり",null,null,null,null,null,null,null,null,null,null,"  ※ 保険薬局の先生へ\n    Grade3のうち網掛け(グレー）に該当する場合や重篤な有害事象を疑う\n    場合は、迷わず患者さんへ医療機関に連絡するよう促してください。"]
[]
["(詳細:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
[null,null,null,null,null,null,null,"なし",null,null,"Grade1",null,null,null,null,null,null,null,null,"Grade2",null,null,null,null,null,null,null,null,null,"Grade3",null,null,null,null,null,null,null,null,null,"発 症・発 現 日",null,null,null,null,null,null,"聞き取り時点での症状"]
["問 1",null,"食欲低下",null,null,null,null,null,null,null,null,"食欲が落ちたが量は半分以上食べられる",null,null,null,null,null,null,null,null,"食欲がおちて、量は半分以下になった",null,null,null,null,null,null,null,null,null,"食べられず体重が減った",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,"グレーコメント\n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,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,"グレー項目","症状項目&G","シートno","症状項目","プルダウン項目","G","G1","G2","G3",null,"NRS"]
["問 2",null,"悪心",null,null,null,null,null,null,null,null,"軽い吐き気があり、食欲が落ちた",null,null,null,null,null,null,null,null,"吐き気で食べる量が減り、体重が減った",null,null,null,null,null,null,null,null,null,"経腸栄養剤を摂取したり、点滴をした",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"以前から",null,null,null,null,null,null,"持続",null,null,"チェックの有無",{"$f":"SUM(AZ24:AZ34)","v":0},null,null,null,null,null,null,null,null,null,null,null,1]
["問 3",null,"嘔吐",null,null,null,null,null,null,null,null,"嘔吐があったがすぐ治まった",null,null,null,null,null,null,null,null,"嘔吐が続き病院を受診した",null,null,null,null,null,null,null,null,null,"嘔吐があり、入院した",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,false,{"$f":"COUNTIF(AY24,\"TRUE\")","v":0},null,"3   (  食べられず体重が減った  ) ",{"$f":"BE24&BG24","v":"食欲低下0"},"問 1","食欲低下","0   (  なし  ) ",0,"なし",null,null,null,2]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,false,{"$f":"COUNTIF(AY25,\"TRUE\")","v":0},null,"3   (  経腸栄養剤を摂取したり、点滴をした  ) ",{"$f":"BE25&BG25","v":"食欲低下1"},null,"食欲低下","1   (  食欲が落ちたが量は半分以上食べられる  ) ",1,"食欲が落ちたが量は半分以上\n食べられる",null,null,null,3]
["問 4",null,"味覚障害",null,null,null,null,null,null,null,null,"味が少し変わったが今まで通り食べられた",null,null,null,null,null,null,null,null,"味が変わって食べる量が減った /食べ物の嗜好が変わった",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,false,{"$f":"COUNTIF(AY26,\"TRUE\")","v":0},null,"3   (  痛みでほとんど食べられなかった  ) ",{"$f":"BE26&BG26","v":"食欲低下2"},null,"食欲低下","2   (  食欲がおちて、量は半分以下になった  ) ",2,"食欲がおちて、\n量は半分以下になった",null,null,null,4]
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["問 5",null,"口腔粘膜炎",null,null,null,null,null,null,null,null,"しみるが食べられる",null,null,null,null,null,null,null,null,"痛みで食べ物を変更・工夫した、治療用の含嗽薬や口腔軟膏を使用した",null,null,null,null,null,null,null,null,null,"痛みでほとんど食べられなかった",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,false,{"$f":"COUNTIF(AY28,\"TRUE\")","v":0},null,"3   (  便回数が以前より1日7回以上増えた  ) ",{"$f":"BE28&BG28","v":"悪心0"},"問 2","悪心","0   (  なし  ) ",0,"なし",null,null,null,6]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,"悪心1",null,"悪心","1   (  軽い吐き気があり、食欲が落ちた  ) ",1,"軽い吐き気があり、食欲が落ちた",null,null,null,7]
["問 6",null,"手足症候群",null,null,null,null,null,null,null,null,"手足が赤くなったが痛みはない",null,null,null,null,null,null,null,null,"手足が赤くなり痛みもあった",null,null,null,null,null,null,null,null,null,"手足に痛みがあり身の回りのことができない（入浴,着脱衣,排泄,食事など）",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,"悪心2",null,"悪心","2   (  吐き気で食べる量が減り、体重が減った  ) ",2,"吐き気で食べる量が減り、体重が減った",null,null,null,8]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,"悪心3",null,"悪心","3   (  経腸栄養剤を摂取したり、点滴をした  ) ",3,"経腸栄養剤を摂取したり、点滴をした",null,null,null,9]
["問 7",null,"皮疹",null,null,null,null,null,null,null,null,"部分的に皮疹が出来た",null,null,null,null,null,null,null,null,"体の10-30％程度に皮疹ができた/見た目が気になり、外出や家族以外の面会を控えている",null,null,null,null,null,null,null,null,null,"体表面積の＞30％以上に症状があり、入浴・睡眠など生活に制限がある",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,"嘔吐0","問 3","嘔吐","0   (  なし  ) ",0,"なし",null,null,null,10]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,"嘔吐1",null,"嘔吐","1   (  嘔吐があったがすぐ治まった  ) ",1,"嘔吐があったがすぐ治まった"]
["問 8",null,"爪囲炎",null,null,null,null,null,null,null,null,"赤くなったが痛みはなし",null,null,null,null,null,null,null,null,"痛みや滲出液を伴う",null,null,null,null,null,null,null,null,null,"症状により歩行や手先の作業に支障がある",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE34&BG34","v":"嘔吐2"},null,"嘔吐","2   (  嘔吐が続き病院を受診した  ) ",2,"嘔吐が続き病院を受診した"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE35&BG35","v":"嘔吐3"},null,"嘔吐","3   (  嘔吐があり、入院した  ) ",3,"嘔吐があり、入院した"]
["問 9",null,"下痢",null,null,null,null,null,null,null,null,"便回数が以前より1～3回/日増えた",null,null,null,null,null,null,null,null,"便回数が以前より4～6回/日増えた",null,null,null,null,null,null,null,null,null,"便回数が以前より1日7回以上増えた",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE36&BG41","v":"味覚障害0"},"問 4","味覚障害","0   (  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,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE37&BG42","v":"味覚障害1"},null,"味覚障害","1   (  味が少し変わったが今まで通り食べられた  ) "]
["問10",null,"便秘",null,null,null,null,null,null,null,null,"便秘して薬剤や浣腸を何回か使用した",null,null,null,null,null,null,null,null,"便秘して薬剤や浣腸を毎回使用した",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE38&BG43","v":"味覚障害2"},null,"味覚障害","2   (  味が変わって食べる量が減った\n　　　　/食べ物の嗜好が変わった  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE39&BG44","v":"口腔粘膜炎0"},"問 5","口腔粘膜炎","0   (  なし  ) "]
["問11",null,"末梢神経障害",null,null,null,null,null,null,null,null,"指先や足裏に違和感があったが今は何ともない",null,null,null,null,null,null,null,null,"身の回り以外の動作に影響がある（買い物、食事の準備、電話の使用、金銭の管理など）",null,null,null,null,null,null,null,null,null,"身の回りの動作への影響がある（入浴,ボタンかけ,排泄,箸の使用など）",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE40&BG70","v":"口腔粘膜炎1"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[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,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE41&BG71","v":"口腔粘膜炎2"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問12",null,"痛みの問診について",null,null,null,null,null,"なし",null,null,"あり",null,"「全く痛みがない」を０、「想像できる最大の痛み」を10として、痛みの程度を数値で教えてください（NRS評価）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"最大",null,null,"最小",null,null,"平均",null,null,null,null,null,null,{"$f":"BE42&BG72","v":"口腔粘膜炎3"},null,"口腔粘膜炎","3   (  痛みでほとんど食べられなかった  ) ",1,"味が少し変わったが今まで通り\n食べられた"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE43&BG73","v":"手足症候群0"},"問 6","手足症候群","0   (  なし  ) ",2,"味が変わって食べる量が減った\n /食べ物の嗜好が変わった"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"痛みで困っていること",null,null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,"なし",null,"鎮痛剤の効果の自覚",null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,"なし",null,null,null,null,null,{"$f":"BE44&BG74","v":"手足症候群1"},null,"手足症候群","1   (  手足が赤くなったが痛みはない  ) ",0,"なし"]
[null,"次のページへ（ICIによる副作用確認）"]
[null,"免疫チェックポイント阻害薬による副作用"]
[null,null,null,null,null,null,null,"なし",null,null,"症状",null,null,null,null,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・発 現 日",null,null,null,null,null,null,"聞き取り時点での症状"]
["問1",null,"間質性肺炎",null,null,null,null,null,null,null,null,"息苦しい",null,null,null,null,null,null,null,null,"乾いた咳がとまらない",null,null,null,null,null,null,null,null,null,"発熱（37.5℃以上）",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE48&BG43","v":"口腔粘膜炎2"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE49&BG44","v":"口腔粘膜炎0"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問2",null,"大腸炎・下痢",null,null,null,null,null,null,null,null,"腹痛",null,null,null,null,null,null,null,null,"下痢が続く",null,null,null,null,null,null,null,null,null,"便に血が混じる",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE50&BG70","v":"口腔粘膜炎1"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE51&BG71","v":"口腔粘膜炎2"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問3",null,"重症筋無力症",null,null,null,null,null,null,null,null,"手足に力が入らない",null,null,null,null,null,null,null,null,"まぶたが下がってくる",null,null,null,null,null,null,null,null,null,"物が二重に見える",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE52&BG70","v":"口腔粘膜炎1"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,"筋肉痛がある",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE53&BG71","v":"口腔粘膜炎2"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問 4",null,"1型糖尿病",null,null,null,null,null,null,null,null,"のどがひどく乾く",null,null,null,null,null,null,null,null,"水を多く飲む",null,null,null,null,null,null,null,null,null,"尿量が増えた",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE54&BG70","v":"口腔粘膜炎1"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE55&BG71","v":"口腔粘膜炎2"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問 5",null,"心筋炎",null,null,null,null,null,null,null,null,"息苦しい",null,null,null,null,null,null,null,null,"むくみ・体重増加",null,null,null,null,null,null,null,null,null,"動悸",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE56&BG72","v":"口腔粘膜炎3"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE57&BG73","v":"口腔粘膜炎0"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問 6",null,"内分泌障害",null,null,null,null,null,null,null,null,"倦怠感",null,null,null,null,null,null,null,null,"体重の増減",null,null,null,null,null,null,null,null,null,"行動変化\n（物忘れ、イライラなど",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE58&BG78","v":"口腔粘膜炎1"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,"悪心・食欲不振",null,null,null,null,null,null,null,null,"飲み込みづらい",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE59&BG79","v":"口腔粘膜炎2"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問 7",null,"静脈血栓塞栓症",null,null,null,null,null,null,null,null,"むくみや腫れ",null,null,null,null,null,null,null,null,"胸の痛み",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE60&BG78","v":"口腔粘膜炎1"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE61&BG79","v":"口腔粘膜炎2"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問8",null,"皮膚障害",null,null,null,null,null,null,null,null,"発疹あり",null,null,null,null,null,null,null,null,"かゆみ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE62&BG78","v":"口腔粘膜炎1"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE63&BG79","v":"口腔粘膜炎2"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問9",null,"神経障害",null,null,null,null,null,null,null,null,"手足のしびれ",null,null,null,null,null,null,null,null,"力の入りにくさがある",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE64&BG80","v":"口腔粘膜炎3"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE65&BG81","v":"口腔粘膜炎0"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問10",null,"ぶどう膜炎",null,null,null,null,null,null,null,null,"目が見えにくい",null,null,null,null,null,null,null,null,"かすみ目",null,null,null,null,null,null,null,null,null,"虫が飛んでいるように見える",null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE66&BG86","v":"口腔粘膜炎1"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE67&BG87","v":"口腔粘膜炎2"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"なし"]
["問11",null,"その他の症状",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月",null,"日",null,null,null,"軽快",null,null,null,null,null,null,{"$f":"BE68&BG86","v":"口腔粘膜炎1"},null,"口腔粘膜炎","1   (  しみるが食べられる  ) "]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以前から",null,null,null,null,null,null,"持続",null,null,null,null,null,null,{"$f":"BE69&BG87","v":"口腔粘膜炎2"},null,"口腔粘膜炎","2   (  痛みで食べ物を変更・工夫した、\n　　　治療用の含嗽薬や口腔軟膏を使用した  ) ",0,"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,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":"BE70&BG75","v":"手足症候群2"},null,"手足症候群","2   (  手足が赤くなり痛みもあった  ) ",1,"しみるが食べられる"]
["＜ 保険薬局からの情報提供（副作用に関する具体的内容等）・提案内容・対応内容 ＞",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"手足症候群3",null,"手足症候群","3   (  手足に痛みがあり身の回りのことができない  ) ",2,"痛みで食べ物を変更・工夫した、\n治療用の含嗽薬や口腔軟膏を使用した"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"皮疹0","問 7","皮疹","0   (  なし  ) ",3,"痛みでほとんど食べられなかった"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"皮疹1",null,"皮疹","1   (  部分的に皮疹が出来た  ) ",0,"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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"皮疹2",null,"皮疹","2   (  体の10-30％程度に皮疹ができた/見た目が\n　気になり、外出や家族以外の面会を控えている  ) ",1,"手足が赤くなったが痛みはない"]
["< 返信欄（病院使用欄） ＞",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"皮疹3",null,"皮疹","3   (  体表面積の＞30％以上に症状があり、\n　　　入浴・睡眠など生活に制限がある  ) ",2,"手足が赤くなり痛みもあった"]
[null,null,"報告内容を確認いたしました。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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":"BE76&BG81","v":"爪囲炎0"},"問 8","爪囲炎","0   (  なし  ) ",3,"手足に痛みがあり身の回りのことができない"]
[null,null,"報告内容を医師へ報告しました　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"爪囲炎1",null,"爪囲炎","1   (  赤くなったが痛みはなし  ) ",0,"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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"爪囲炎2",null,"爪囲炎","2   (  痛みや滲出液を伴う  ) ",1,"部分的に皮疹が出来た"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"爪囲炎3",null,"爪囲炎","3   (  症状により歩行や手先の作業に支障がある  ) ",2,"体の10-30％程度に皮疹ができた\n /見た目が気になり、外出や家族以外の\n面会を控えている"]
[null,"返信日：",null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,"病院名",null,null,"前橋赤十字病院",null,null,null,null,null,null,null,null,null,"所属",null,null,null,null,null,null,null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,"下痢0","問 9","下痢","0   (  なし  ) ",3,"体表面積の＞30％以上に症状があり、入浴・睡眠など生活に制限がある"]
[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,"下痢1",null,"下痢","1   (  便回数が以前より1～3回/日増えた  ) ",0,"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,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":"BE82&BG87","v":"下痢2"},null,"下痢","2   (  便回数が以前より4～6回/日増えた  ) ",1,"赤くなったが痛みはなし"]
["＊_＊_＊_＊_",null,null,null,null,"調剤薬局様へ　",null,null,null,null,null,null,null,null,"＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"下痢3",null,"下痢","3   (  便回数が以前より1日7回以上増えた  ) ",2,"痛みや滲出液を伴う"]
[null,null,null,null,null,null,null,null,null,null,null,null,"必要事項をご記入頂いた上でFAXにて送信ください。",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,"便秘0","問 10","便秘","0   (  なし  ) ",3,"症状により歩行や手先の作業に支障がある"]
[null,null,null,null,null,"宛先病院名",null,null,null,null,null,null,"前橋赤十字病院　薬剤部",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"便秘1",null,"便秘","1   (  便秘して薬剤や浣腸を何回か使用した  ) ",0,"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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"便秘2",null,"便秘","2   (  便秘して薬剤や浣腸を毎回使用した  ) ",1,"便回数が以前より1～3回/日増えた"]
[null,null,null,null,null,"FAX番号",null,null,null,null,null,null,"027-225-5258",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"末梢神経障害0","問 11","末梢神経障害","0   (  なし  ) ",2,"便回数が以前より4～6回/日増えた"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"末梢神経障害1",null,"末梢神経障害","1   (  指先や足裏に違和感があったが\n　　今は何ともない  ) ",3,"便回数が以前より1日7回以上増えた"]
[null,null,null,null,null,"レポート送信時の注意点",null,null,null,null,null,null,"次回受診日の前日10時までに送信をお願いいたします\nFAXの送り間違えには十分ご注意ください\n当院ではヘルスケアパスポートでの送信を推奨しています",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"末梢神経障害2",null,"末梢神経障害","2   (  身の回り以外の動作に影響がある（買い物、食事の準備、電話の使用、金銭の管理など）  ) ",0,"なし"]
[null,null,null,null,null,null,null,null,null,null,null,"（受付時間終了後につきましては、　翌営業日の対応となりますのでご協力の程よろしくお願いいたします。）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"末梢神経障害3",null,"末梢神経障害","3   (  身の回りの動作への影響がある  ) ",1,"便秘して薬剤や浣腸を何回か\n使用した"]
[null,null,null,null,null,null,null,null,null,null,null,null,"※トレーシングレポートは疑義照会ではありません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"便秘して薬剤や浣腸を毎回使用した"]
["＊_＊_＊＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_＊_",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"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,null,null,null,null,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,"指先や足裏に違和感があったが\n今は何ともない"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,2,"身の回り以外の動作に影響がある（買い物、\n食事の準備、電話の使用、金銭の管理など）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"身の回りの動作への影響がある"]