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{"sheet":"使用上のご注意・印刷ボタン","index":0,"n_rows":204,"n_cols":20,"rows_kept":204,"cut":false,"hidden":false,"merged":[[21,2,22,39],[23,2,24,39],[25,1,26,1],[44,2,45,39],[46,1,46,16],[30,2,34,39],[38,2,39,39],[41,2,42,39],[47,2,48,38],[4,1,7,38],[25,2,27,39],[23,1,24,1],[21,1,22,1],[29,2,29,39],[15,1,17,1],[11,0,11,15],[13,1,14,1],[13,2,14,39],[15,2,18,39],[19,1,20,1],[19,2,20,39],[8,1,10,38],[35,2,36,39],[28,0,28,39],[200,4,201,35],[203,19,205,35],[55,2,57,38],[192,4,193,34],[49,2,50,38],[52,0,53,39]]}
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[null,"産科医療特別給付事業　給付申請用　専用診断書\nExcel版使用上のご注意"]
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[null,"　 『産科医療特別給付事業　給付申請用 専用診断書　Excel版』をご使用いただくに際しては、以下の点について十分ご留意くださいますようお願い申し上げます。"]
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["【診断書の作成手順について】"]
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[null,"①","各シートに漏れなく入力してください。"]
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[null,"②","すべての項目の入力が終わりましたら、表紙以降の全シートをA4用紙に印刷してください。\nなお、本シート最下部の「一括印刷ボタン」を活用いただきますと、提出に必要なすべてのシートをまとめて印刷することができます（※Excelファイルのままご提出いただくことはできません）。"]
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[null,"③","印刷後、「所見-3」(9ページ)の『医師氏名』欄に、自筆でご署名、ご捺印をお願いします。"]
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[null,"④","10～11ページに、別にプリント（現像）した児の写真を糊で貼り付けてください。"]
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[null,"⑤","13ページに、必要な検査データ、NICUサマリー等をホチキスで止めてください。"]
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[null,"⑥","最後に、すべてのページをそろえて表紙に印した2箇所をホチキスで止めてください（クリップ等は不可）。以上で作成完了です。"]
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["【その他のご注意】"]
[null,"・","あらかじめ設定してあるセルの保護等の制御設定を変更（解除）しないようお願いします。"]
[null,"・","万一、所定のスペース内で書ききれない場合は、別の書式（Word等、書式自由）で作成、印刷した上で、印刷後の診断書の該当ページにホチキスで止めてください。\nまた、追加資料を印刷した診断書と一緒にホチキス止めした場合は、診断書のページ番号から連続する通し番号を記入してください。"]
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[null,"・","印刷後に修正（追記、訂正等）が必要となった場合は、該当箇所に直接手書きでご修正いただいて結構ですが、必ず診断医の訂正印を押してください。"]
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[null,"・","診断書の内容は変更することがありますので、次回以降、診断書を作成いただく場合は、必ずその都度、ダウンロードを行ってください。"]
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[null,"・","万一、これらが守られていない場合、診断書を無効とさせていただくことや、訂正や再度押印をお願いすることがありますので、あらかじめご了承ください。"]
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[null,"・","個人情報等が含まれますので、作成後の診断書ファイルの取扱いには十分にご注意ください。"]
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[null,"＊セル内での改行について"]
[null,null,"Windowsの場合は、「Alt」キーを押しながら「Enter」キーを押すと、セルの中で改行を行うことができます。"]
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[null,null,"Macの場合は、「control」キーと「option」キーを同時に押しながら、「return」 キーを押すと、セルの中で改行を行うことができます。"]
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["≪すべての工程が完了しましたら、診断書を給付申請者へお渡しください≫\n本シート最下部の「一括印刷ボタン」からまとめて印刷することができます"]
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[null,"※","診断書に添付いただく検査や写真撮影、動画について、ご確認いただきたい内容を以下のチラシに記載しておりますので、あわせてご確認をお願いします。\n"]
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[null,null,null,"※","診断書作成とは別に、上記のチラシ類も印刷することができます。\n給付申請者へのご説明等にご活用ください。"]
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[null,null,null,"※","すべてのシートについて、入力漏れがないことを今一度ご確認いただき、印刷を行ってください。"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"このボタンをクリックすると、ご提出に必要なすべてのシートを一括印刷できます。（チラシは印刷されません）"]

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["産科医療特別給付事業　給付申請用　専用診断書\nExcel版"]
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["診断書の印刷後、以下の事項につき必ずご対応ください。"]
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["　　≪「医師氏名」欄の記入≫\n\n　　■「所見-3」(9ﾍﾟｰｼﾞ)の「医師氏名」欄に、自筆でご署名、\n　　　 ご捺印をお願いします。\n\n\n　　≪写真・検査データ等の貼付≫\n\n　　■10～11ページに、別にプリント（現像）した児の写真を\n　　　 糊で貼り付けてください。\n　　■13ページに、必要な検査データ、NICUサマリー等を\n　　　 ホチキスで止めてください。\n\n\n　　≪ホチキス留め≫\n\n　　■すべてのページをそろえて表紙に印した2箇所を\n　　　ホチキスで留めてください。（クリップ等は不可）\n\n\n　　"]
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[null,null,"産科医療特別給付事業"]
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[null,null,"給付申請用　専用診断書"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2025年1月版"]
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[null,null,"この診断書は、産科医療特別給付事業における給付申請時に必要な脳性麻痺に関する診断書です。\nこの診断書の作成にあたっては、以下の点にご注意ください。"]
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[null,null,"　　＜作成にあたっての注意点＞"]
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[null,null,"　１．　児が、次に定める期間中に以下の条件（在胎週数、出生体重）で出生されていることをご確認\n　　ください。\n　　・　平成21年（2009年）以降平成26年（2014年）末日までに出生した児：\n　　　　在胎週数28週以上33週未満で出生、または　在胎週数33週以上かつ2,000g未満で出生\n　　・　平成27年（2015年）以降令和３年（2021年）末日までに出生した児：\n　　　　在胎週数28週以上32週未満で出生、または　在胎週数32週以上かつ1,400g未満で出生\n　\n　２．　産科医療特別給付事業では、この診断書は次のいずれかの条件を満たす医師が作成すること\n　　としています。\n\n　　① 身体障害者福祉法第十五条第一項の規定に基づく障害区分「肢体不自由」の認定に係る小児の\n　　　　診療等を専門分野とする医師\n　　② 日本小児神経学会の定める小児神経専門医の認定を受けた医師\n　　③ 日本神経学会の定める神経内科専門医の認定を受けた医師\n\n　３．　不明な点等がありましたら、以下のお問い合わせ先までご照会ください。\n\n　　給付の可否についての最終的な判断に関しては、産科医療特別給付事業の運営組織である\n　　公益財団法人日本医療機能評価機構が審査委員会において審査を行い、給付対象の認定を\n　　行います。"]
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[null,null,null,null,null,null,null,"【診断書作成に関するお問い合わせ先】\n公益財団法人日本医療機能評価機構\n産科医療補償制度運営部（産科医療特別給付事業）　審査課\nTEL：03-5217-3188\n受付時間：午前9時～午後5時（土日祝日・年末年始を除く）"]
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[null,null,"＜産科医療特別給付事業運営組織使用欄＞"]
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[null,null,null,"T"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ｂ-205 (4) 15.01(改)-E",null,"E-201 (1) 24.11"]

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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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"総括－1"]
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[null,null,null,null,"（総括表）　脳性麻痺診断書"]
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[]
[null,null,null,null,"児の氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",null,null,null,null,null,"保護者氏名"]
[]
[null,null,null,null,"フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"西暦",null,null,20,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,null,null,null,"男"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女"]
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[null,null,null,null,"①　診断（脳性麻痺）"]
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[]
[null,null,null,null,null,null,"痙直型",null,null,null,null,null,null,"アテトーゼ型",null,null,null,null,null,null,null,null,null,"失調型",null,null,null,null,null,null,"低緊張型",null,null,null,null,null,null,null,"混合型",null,null,null,null,null,null,"その他",null,null,null,"（",null,null,null,null,null,null,null,"）"]
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[null,null,null,null,"②　現在の身体測定値"]
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[null,null,null,null,"■体重、身長、頭囲の3項目を同一日に測定してください。"]
[]
[null,null,null,null,"測定日（西暦 20",null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日）",null,null,"体重（",null,null,null,null,null,null,null,"）ｋｇ",null,null,null,"身長（",null,null,null,null,null,null,null,"）ｃｍ",null,null,null,"頭囲（",null,null,null,null,null,null,"）ｃｍ"]
[]
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[null,null,null,null,"③　出生時から新生児期までの状況・経過\n（※産科医療補償制度に申請歴のある方は、NICUサマリー添付および記入は不要です。）"]
[]
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[null,null,null,null,"NICUサマリー添付：",null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,"有",null,null,null,null,"NICUサマリーが「有」の場合は、必ず写しを添付してください。\nNICUサマリーを添付する場合は、下欄への記入は不要です。"]
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[null,null,null,null,"■NICUサマリーが「無」の場合は、各項目について、該当するものすべてにレ点を記入してくだ\n　さい。状況等がわからない場合は、「不明」にレ点を記入してください。"]
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[null,null,null,null,"【参考とした情報】",null,null,null,null,null,null,null,null,null,"分娩機関からの情報",null,null,null,null,null,null,null,null,null,null,"NICUサマリー",null,null,null,null,null,null,null,null,"家族からの情報",null,null,null,null,null,null,null,null,null,"その他",null,null,null,"（",null,null,null,null,null,null,null,null,"）"]
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[null,null,null,null,"・在胎週数：",null,null,null,null,null,"（",null,null,null,null,"）","週",null,"（",null,null,null,null,"）","日",null,null,null,null,null,"不明"]
[]
[null,null,null,null,"・分娩の状況：",null,null,null,null,null,null,null,"正常経腟分娩",null,null,null,null,null,null,null,null,"吸引分娩・鉗子分娩",null,null,null,null,null,null,null,null,null,null,"超緊急帝王切開",null,null,null,null,null,null,null,null,null,"緊急帝王切開",null,null,null,null,null,null,null,null,"予定帝王切開"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"クリステレル胎児圧出法",null,null,null,null,null,null,null,null,null,null,null,null,"陣痛誘発・促進",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,"不明"]
[]
[null,null,null,null,"・分娩時診断：",null,null,null,null,null,null,null,"前置胎盤",null,null,null,null,null,null,"常位胎盤早期剥離",null,null,null,null,null,null,null,null,null,null,"子宮破裂",null,null,null,null,null,null,"子癇",null,null,null,null,"臍帯脱出",null,null,null,null,null,null,"胎児機能不全"]
[]
[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,"不明"]
[]
[null,null,null,null,"・アプガースコア：",null,null,null,null,null,null,null,"１分後",null,null,"（",null,null,null,"）","点",null,"・","５分後",null,null,"（",null,null,null,"）","点",null,"・","10分後",null,null,null,"（",null,null,null,"）","点",null,null,null,null,"不明"]
[]
[null,null,null,null,"・出生時の状況："]
[]
[]
[null,null,null,null,"・出生時の蘇生処置等：",null,null,null,null,null,null,null,null,null,null,null,null,"酸素投与",null,null,null,null,null,null,"バッグ・マスク",null,null,null,null,null,null,null,null,"気管挿管",null,null,null,null,"（","生後",null,null,null,null,null,"分",null,"）",null,null,null,"胸骨圧迫"]
[]
[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,"蘇生処置無",null,null,null,null,null,null,null,"不明"]
[]
[null,null,null,null,"・新生児期の治療等：",null,null,null,null,null,null,null,null,null,null,null,null,"人工呼吸管理",null,null,null,null,null,null,"（",null,null,null,"日間",null,null,"）",null,null,"抗てんかん薬投与",null,null,null,null,null,null,null,null,null,"脳低温療法",null,null,null,null,null,"（",null,null,null,"日間",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,"治療無",null,null,null,null,null,"不明"]
[]
[null,null,null,null,"■上記以外の状況について特記すべき事項があれば記入してください。"]
[]
[]
[]
[null,null,null,null,"④　新生児期からの障害の経過・現症"]
[]
[null,null,null,null,"■貴科受診までの経緯と、その後の経過について記入してください。\n■経過の中で退行を認める場合は、生後の発達の状況（例：頚定、寝返り、坐位、四つ這い等の獲得時期等）や退行の時期等についてもわかる範囲で記入してください。\n■本欄に書ききれない場合は、裏面に記入、または別紙に記入し添付してください。"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
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[]
[]
[null,null,null,null,1]
[]
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[null,null,null,"09"]
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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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"総括－2"]
[]
[]
[]
[null,null,null,null,"⑤　その他参考となる合併症"]
[]
[null,null,null,null,"　・知的障害（精神発達遅滞）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,"有",null,"➡",null,"（精神発達：およそ",null,null,null,null,null,null,null,null,null,null,null,"歳",null,"※",null,null,null,"ヶ月",null,null,null,null,"判定不能",null,null,null,null,null,"）"]
[]
[null,null,null,null,null,null,null,null,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」のみの判定でも可。ただし、判定が１歳未満の場合は、\n　 「0歳▲ヶ月」と記入してください。"]
[]
[]
[null,null,null,null,"　・合併症",null,null,null,null,null,null,null,"無",null,null,null,"有",null,"➡",null,null,null,null,"呼吸障害",null,null,null,null,null,null,"嚥下障害",null,null,null,null,null,null,"てんかん（",null,null,null,null,null,null,"点頭てんかん",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,"胃食道逆流症",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,"⑥　治療及びリハビリテーションの状況"]
[]
[null,null,null,null,null,null,"薬物使用有",null,null,null,null,null,null,null,null,"抗てんかん薬",null,null,null,null,null,null,null,null,"筋弛緩薬",null,null,null,null,null,null,"抗潰瘍薬等",null,null,null,null,null,null,null,"向精神病薬"]
[]
[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,"酸素使用有　（",null,null,null,null,null,null,null,null,null,"常時",null,null,null,null,"夜間のみ",null,null,null,null,null,null,null,"必要時",null,null,null,"）",null,null,null,null,null,"気管挿管 ・ 気管切開有"]
[]
[null,null,null,null,null,null,"人工呼吸器の使用有",null,null,null,null,null,null,null,null,null,null,"（",null,null,null,"常時",null,null,null,null,null,"夜間のみ",null,null,null,null,null,null,"必要時",null,null,null,"）"]
[]
[null,null,null,null,null,"医療機関受診",null,null,null,null,null,null,null,null,null,null,null,null,null,"受診していない",null,null,null,null,null,null,null,null,null,null,"年に数回",null,null,null,null,null,null,null,null,"月に1～2回",null,null,null,null,null,null,null,null,"月に3回以上"]
[]
[]
[null,null,null,null,null,"リハビリテーション",null,null,null,null,null,null,null,null,null,null,null,null,null,"受けていない",null,null,null,null,null,null,null,null,null,null,"年に数回",null,null,null,null,null,null,null,null,"月に1～2回",null,null,null,null,null,null,null,null,"月に3回以上"]
[]
[]
[null,null,null,null,"■上記以外の状況について特記すべき事項があれば記入してください。\n　（虐待等を疑う所見があれば記入してください。）"]
[]
[]
[]
[]
[null,null,null,null,"⑦　日常生活及び介助の状況"]
[]
[null,null,null,null,"　・現在の主な生活場所",null,null,null,null,null,null,null,null,null,null,null,null,null,"在宅（通所・通園・通学を含む）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"病院",null,null,null,null,"入所施設",null,null,null,null,null,null,"その他",null,null,null,"（",null,null,null,null,null,null,null,"）"]
[]
[null,null,null,null,"　・日常生活の状況"]
[]
[null,null,null,null,null,"食事",null,null,null,null,null,null,null,"経口摂取",null,null,null,null,"[",null,null,"介助不要",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助",null,null,null,"]"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"経管栄養",null,null,null,null,"[",null,null,"経鼻胃管",null,null,null,null,null,null,null,"胃ろう",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,"経口摂取 ・経管栄養併用（経口摂取の介助状況及び経管栄養の内容については上部に記入してください）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"経静脈栄養"]
[]
[null,null,null,null,null,"排泄",null,null,null,null,null,null,null,"おむつ不要",null,null,null,null,null,null,"[",null,null,"介助不要",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助",null,null,null,"]"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"おむつ使用",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,"洗面・更衣",null,null,null,null,null,null,null,"介助不要",null,null,null,null,null,null,null,"一部介助",null,null,null,null,null,null,null,"全介助"]
[]
[null,null,null,null,null,"移動手段",null,null,null,null,null,null,null,"車椅子・バギー",null,null,null,null,null,null,null,null,null,"歩行器",null,null,null,null,null,"杖",null,null,null,"下肢装具",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,"■上記以外の状況について特記すべき事項があれば記入してください。"]
[]
[]
[]
[null,null,null,null,"⑧　家族歴"]
[]
[null,null,null,null,"■血縁者（児の父母または兄弟姉妹に限る）の中に、児の運動障害に関連する可能性がある小児期からの運動機能障害または精神運動発達遅滞があるかどうかを、記入してください。"]
[]
[]
[null,null,null,null,null,null,"該当する家族歴なしまたは不明"]
[]
[null,null,null,null,null,null,"該当する家族歴がある(診断がついている場合は疾患名、そうでなければ症状、状態)"]
[]
[null,null,null,null,null,null,"疾患名または症状、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,null,null,"）","児との続柄",null,null,null,null,null,"（",null,null,null,null,"）"]
[]
[null,null,null,null,null,null,"疾患名または症状、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,null,null,"）","児との続柄",null,null,null,null,null,"（",null,null,null,null,"）"]
[]
[null,null,null,null,"⑨　その他の特記事項"]
[]
[null,null,null,null,"■障害の程度や予後等について特記すべき事項があれば記入してください。"]
[]
[]
[]
[]
[null,null,null,null,2]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,0,null,null,0]
[null,null,null,null,null,null,1,null,null,1]
[null,null,null,null,null,null,2,null,null,2]
[null,null,null,null,null,null,3,null,null,3]
[null,null,null,"父",null,null,4,null,null,4]
[null,null,null,"母",null,null,null,null,null,5]
[null,null,null,"兄",null,null,null,null,null,6]
[null,null,null,"弟",null,null,null,null,null,7]
[null,null,null,"姉",null,null,null,null,null,8]
[null,null,null,"妹",null,null,null,null,null,9]
[null,null,null,null,null,null,null,null,null,10]
[null,null,null,null,null,null,null,null,null,11]

{"sheet":"P3 総括-3","index":4,"n_rows":85,"n_cols":56,"rows_kept":85,"cut":false,"hidden":false,"merged":[[84,4,85,57],[6,4,8,57],[64,7,65,54],[55,7,56,18],[57,9,58,56],[59,9,61,56],[62,9,63,56],[55,19,56,54],[28,28,28,47],[22,22,24,23],[25,22,27,23],[82,5,83,56],[79,4,81,57],[70,28,71,47],[66,22,68,23],[66,25,68,27],[66,28,66,47],[67,28,68,47],[66,5,68,20],[76,6,77,55],[28,5,31,20],[28,22,31,23],[28,25,31,27],[69,28,69,47],[73,6,75,55],[69,5,71,20],[69,22,71,23],[69,25,71,27],[32,6,33,56],[29,28,31,47],[34,7,35,18],[43,7,44,18],[22,5,24,20],[22,28,22,47],[23,28,27,47],[25,6,27,20],[22,25,24,27],[25,25,27,27],[53,6,54,56],[47,55,48,55],[49,28,49,47],[47,10,48,13],[47,14,48,14],[47,15,48,54],[45,10,46,54],[50,25,52,27],[50,28,52,47],[49,5,52,20],[36,9,37,56],[41,9,42,56],[38,9,40,56],[50,22,52,23],[43,19,44,54],[0,52,1,57],[2,4,3,57],[4,4,5,57],[15,4,16,57],[17,5,21,27],[17,28,21,47],[17,48,19,56],[20,48,21,50],[20,51,21,53],[20,54,21,56],[12,4,14,57],[9,4,11,57]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"総括－3"]
[]
[null,null,null,null,"⑩　除外基準"]
[]
[null,null,null,null,"１．先天性要因"]
[]
[null,null,null,null,"■１）から５）の各項目について、有無を選択してください。\n■１）から５）の各項目について、「有」を選択した場合は、"]
[]
[]
[null,null,null,null,"（１）右の枠内に疾患名を記入してください。また、脳奇形が「有」の場合は、両側性の広範な\n　脳奇形の有無を選択してください。"]
[]
[]
[null,null,null,null,"（２）これらの疾患が重度の運動障害の主な原因と推定されるか否かについて選択し、また、重\n　度の運動障害の主な原因でないと推定される場合は、判断の理由等を下欄に記入してください。"]
[]
[]
[null,null,null,null,"■なお、これらの疾患と重度の運動障害との関係についての最終判断は、審査委員会で行います。"]
[]
[null,null,null,null,null,"先天性要因\n（いずれかにレ点を記入）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"先天性要因が「有」の場合は\n疾患名を記入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"重度の運動障害の主な原因\nと推定されるか否か\n（いずれかにレ点を記入）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主な原因\nでない",null,null,"主な原因\nである",null,null,"どちらとも\n言えない"]
[]
[null,null,null,null,null,"１）脳奇形",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,"有➡",null,null,"（疾患名）"]
[]
[]
[null,null,null,null,null,null,"（脳奇形が「有」の場合）\n両側性の広範な脳奇形",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,"有➡"]
[]
[]
[null,null,null,null,null,"２）染色体異常\n　検査を実施していない場合は\n　「染色体異常を示唆する所見」の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,"有➡",null,null,"（疾患名）"]
[]
[]
[]
[null,null,null,null,null,null,"＊染色体検査（Ｇバンド検査）の実施状況"]
[]
[null,null,null,null,null,null,null,"検査を実施している"]
[]
[null,null,null,null,null,null,null,null,null,"検査結果報告書がある（※必ず検査結果報告書を添付してください）"]
[]
[null,null,null,null,null,null,null,null,null,"検査結果報告書はない\n（※必ず検査結果が記載された記録（医師記録、診療情報提供書等）を添付してください）"]
[]
[]
[null,null,null,null,null,null,null,null,null,"検査結果報告書、検査結果が記載された記録（医師記録、診療情報提供書等）いずれもなし"]
[]
[null,null,null,null,null,null,null,"検査を実施していない",null,null,null,null,null,null,null,null,null,null,null,"→検査を実施していない場合は、以下に必ずその理由を記入してください。"]
[]
[null,null,null,null,null,null,null,null,null,null,"染色体異常を疑う身体所見を認めなかったため"]
[]
[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,"３）遺伝子異常\n　検査を実施していない場合は\n　「遺伝子異常を示唆する所見」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,"（疾患名）"]
[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,"有➡"]
[]
[]
[null,null,null,null,null,null,"＊遺伝子検査の実施状況"]
[]
[null,null,null,null,null,null,null,"検査を実施している"]
[]
[null,null,null,null,null,null,null,null,null,"検査結果報告書がある（※必ず検査結果報告書を添付してください）"]
[]
[null,null,null,null,null,null,null,null,null,"検査結果報告書はない\n（※必ず検査結果が記載された記録（医師記録、診療情報提供書等）を添付してください）"]
[]
[]
[null,null,null,null,null,null,null,null,null,"検査結果報告書、検査結果が記載された記録（医師記録、診療情報提供書等）いずれもなし"]
[]
[null,null,null,null,null,null,null,"検査を実施していない"]
[]
[null,null,null,null,null,"４）先天性代謝異常",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,"有➡",null,null,"（疾患名）"]
[]
[]
[null,null,null,null,null,"５）先天異常",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,"有➡",null,null,"（疾患名）"]
[]
[]
[]
[null,null,null,null,null,null,"＊先天性要因に該当する疾患が「有」で、「この疾患は重度の運動障害の主な原因でない」と推定される場合は、以下に判断の理由等を記入してください。"]
[]
[]
[]
[]
[]
[null,null,null,null,"■特定の先天異常に該当する疾患・症候群とは言えないが、他に先天性要因を疑う所見（例：小\n　頭、特異顔貌、小顎、多指、内臓奇形等）がある場合は、その所見を記入してください。"]
[]
[]
[]
[]
[null,null,null,null,3]

{"sheet":"P4 総括-4","index":5,"n_rows":80,"n_cols":55,"rows_kept":80,"cut":false,"hidden":false,"merged":[[0,52,1,57],[4,4,5,57],[6,4,7,57],[8,4,9,57],[10,4,11,57],[12,4,14,57],[15,4,16,57],[17,5,21,27],[17,28,21,47],[17,48,19,56],[20,48,21,50],[20,51,21,53],[20,54,21,56],[31,5,39,20],[31,28,31,47],[32,28,39,47],[34,22,36,23],[34,25,36,27],[22,5,30,20],[22,28,22,47],[23,28,30,47],[25,22,27,23],[25,25,27,27],[49,5,57,20],[49,28,49,47],[50,28,57,47],[52,22,54,23],[52,25,54,27],[40,5,48,20],[40,28,40,47],[41,28,48,47],[43,22,45,23],[43,25,45,27],[73,6,77,55],[79,4,80,57],[58,5,66,20],[58,28,58,47],[59,28,66,47],[70,6,72,55],[61,22,63,23],[61,25,63,27]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"総括－4"]
[]
[]
[]
[null,null,null,null,"２．新生児期の要因"]
[]
[null,null,null,null,"■１）から５）の各項目について、有無を選択してください。"]
[]
[null,null,null,null,"■１）から５）の各項目について、「有」を選択した場合は、"]
[]
[null,null,null,null,"（１）右の枠内に疾患名等を記入してください。"]
[]
[null,null,null,null,"（２）これらの疾患等が重度の運動障害の主な原因と推定されるか否かについて選択し、また、重\n　度の運動障害の主な原因でないと推定される場合は、判断の理由等を下欄に記入してください。"]
[]
[]
[null,null,null,null,"■なお、これらの疾患等と重度の運動障害との関係についての最終判断は、審査委員会で行います。"]
[]
[null,null,null,null,null,"新生児期の要因\n（いずれかにレ点を記入）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"新生児期の要因が「有」の場合は\n疾患名等を記入",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"重度の運動障害の主な原因\nと推定されるか否か\n（いずれかにレ点を記入）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"主な原因\nでない",null,null,"主な原因\nである",null,null,"どちらとも\n言えない"]
[]
[null,null,null,null,null,"１）髄膜炎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（起因菌・発症時期等）"]
[]
[]
[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,"有➡"]
[]
[]
[]
[]
[]
[null,null,null,null,null,"２）脳炎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（起因菌・発症時期等）"]
[]
[]
[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,"有➡"]
[]
[]
[]
[]
[]
[null,null,null,null,null,"３）その他の神経疾患",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（疾患名）"]
[]
[]
[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,"有➡"]
[]
[]
[]
[]
[]
[null,null,null,null,null,"４）虐待",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（所見）"]
[]
[]
[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,"有➡"]
[]
[]
[]
[]
[]
[null,null,null,null,null,"５）その他の外傷等",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（疾患名・所見等）"]
[]
[]
[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,"有➡"]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"＊新生児期の要因に該当する疾患等が「有」で、「この疾患等は重度の運動障害の主な原因でない」と推定される場合は、以下に判断の理由等を記入してください。"]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,4]

{"sheet":"P5 検査-1","index":6,"n_rows":112,"n_cols":55,"rows_kept":112,"cut":false,"hidden":false,"merged":[[79,4,80,57],[14,4,15,30],[12,4,13,57],[63,5,72,6],[25,5,34,6],[44,5,53,6],[28,21,29,22],[17,5,19,14],[66,21,67,22],[47,21,48,22],[47,19,48,20],[47,25,48,28],[66,15,67,18],[47,15,48,18],[66,25,67,28],[66,23,67,24],[17,72,19,74],[28,23,29,24],[28,25,29,28],[17,60,19,64],[17,70,19,71],[17,65,19,66],[17,67,19,69],[17,15,19,28],[1,10,2,51],[28,19,29,20],[4,4,11,57],[14,50,16,51],[14,38,16,47],[0,52,1,57],[14,54,16,55],[17,29,19,56],[28,15,29,18],[20,29,38,56],[30,8,31,11],[26,8,27,11],[45,8,46,11],[49,8,50,11],[64,8,65,11],[39,29,57,56],[58,29,76,56],[47,23,48,24],[66,19,67,20],[68,8,69,11]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査－1"]
[null,null,null,null,null,null,null,null,null,null,"検査結果"]
[]
[]
[null,null,null,null,"１．頭部画像検査\n■３回以上実施した場合は、生後から早期、中期、最近の代表的な３回分を記入してください。\n（「画像上は、除外基準に該当しないことが明らかである」と判断できる場合は、直近のものだけでも可能です。ただし、審査委員会において、画像が不鮮明等の理由により、再提出を求める場合があります。）\n※産科医療補償制度に申請歴のある方は、直近のものだけでも可能です。ただし、その後の頭部画像検査の確認が必要と判断される場合には、追加の提出を求める場合があります。"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,"■頭部画像検査については、以下に所見を記入の上、画像データを必ず添付してください（フィルムも可）。"]
[]
[null,null,null,null,"■読影報告書を添付する場合は、下欄の記入は不要です。",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,"読影報告書添付：",null,null,null,null,null,null,null,null,null,null,null,"有",null,null,null,"無"]
[]
[]
[null,null,null,null,null,"頭部画像検査名\n（いずれかにレ点を記入）",null,null,null,null,null,null,null,null,null,"実 施 年 月 日",null,null,null,null,null,null,null,null,null,null,null,null,null,"所　見"]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"MRI"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,"・"]
[]
[null,null,null,null,null,null,null,null,"CT"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"MRI"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,"・"]
[]
[null,null,null,null,null,null,null,null,"CT"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,"MRI"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,"・"]
[]
[null,null,null,null,null,null,null,null,"CT"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,5]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2009,null,null,null,null,1,null,null,null,null,1]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2010,null,null,null,null,2,null,null,null,null,2]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2011,null,null,null,null,3,null,null,null,null,3]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2012,null,null,null,null,4,null,null,null,null,4]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2013,null,null,null,null,5,null,null,null,null,5]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2014,null,null,null,null,6,null,null,null,null,6]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2015,null,null,null,null,7,null,null,null,null,7]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2016,null,null,null,null,8,null,null,null,null,8]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2017,null,null,null,null,9,null,null,null,null,9]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2018,null,null,null,null,10,null,null,null,null,10]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2019,null,null,null,null,11,null,null,null,null,11]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2020,null,null,null,null,12,null,null,null,null,12]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2021,null,null,null,null,null,null,null,null,null,13]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2022,null,null,null,null,null,null,null,null,null,14]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2023,null,null,null,null,null,null,null,null,null,15]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2024,null,null,null,null,null,null,null,null,null,16]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2025,null,null,null,null,null,null,null,null,null,17]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2026,null,null,null,null,null,null,null,null,null,18]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2027,null,null,null,null,null,null,null,null,null,19]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2028,null,null,null,null,null,null,null,null,null,20]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,2029,null,null,null,null,null,null,null,null,null,21]
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{"sheet":"P6 検査-2","index":7,"n_rows":114,"n_cols":60,"rows_kept":114,"cut":false,"hidden":false,"merged":[[0,52,1,57],[4,4,5,57],[6,16,8,17],[6,18,8,19],[6,21,8,22],[6,23,8,24],[6,4,8,15],[6,26,8,56],[9,4,11,57],[12,59,28,74],[12,6,13,25],[12,26,13,40],[12,41,13,55],[14,6,25,14],[14,15,16,25],[14,26,16,30],[14,31,16,32],[14,33,16,35],[14,36,16,37],[14,38,16,40],[14,41,16,55],[17,15,19,25],[17,26,19,30],[17,31,19,32],[17,33,19,35],[17,36,19,37],[17,38,19,40],[17,41,19,55],[20,41,22,55],[23,15,25,25],[23,26,25,30],[23,31,25,32],[23,33,25,35],[23,36,25,37],[23,38,25,40],[23,41,25,55],[20,15,22,25],[20,26,22,30],[20,31,22,32],[20,33,22,35],[20,36,22,37],[20,38,22,40],[30,6,31,14],[32,6,32,14],[32,15,34,25],[32,26,34,30],[32,31,34,32],[32,33,34,35],[26,41,28,55],[29,15,31,25],[29,26,31,30],[29,31,31,32],[29,33,31,35],[29,36,31,37],[29,38,31,40],[29,41,31,55],[26,15,28,25],[26,26,28,30],[26,31,28,32],[26,33,28,35],[26,36,28,37],[26,38,28,40],[32,36,34,37],[32,38,34,40],[32,41,34,55],[33,10,34,13],[35,10,36,13],[35,15,37,25],[35,26,37,30],[35,31,37,32],[35,33,37,35],[35,36,37,37],[35,38,37,40],[35,41,37,55],[38,15,40,25],[38,26,40,30],[38,31,40,32],[38,33,40,35],[38,36,40,37],[38,38,40,40],[38,41,40,55],[41,41,43,55],[44,6,46,25],[44,26,46,30],[44,31,46,32],[44,33,46,35],[44,36,46,37],[44,38,46,40],[44,41,46,55],[41,6,43,25],[41,26,43,30],[41,31,43,32],[41,33,43,35],[41,36,43,37],[41,38,43,40],[52,42,56,54],[54,10,55,11],[54,12,55,23],[58,5,60,56],[61,7,62,8],[61,9,62,55],[48,42,49,43],[48,44,49,48],[48,49,49,50],[48,51,49,55],[50,10,51,11],[50,12,51,23],[50,42,51,54],[47,26,56,30],[47,31,56,32],[47,33,56,35],[47,36,56,37],[47,38,56,40],[48,8,49,23],[52,10,53,11],[52,12,53,23],[68,4,71,57],[72,5,78,56],[80,4,81,57],[63,7,64,8],[63,9,64,12],[63,13,64,13],[63,14,64,55],[63,56,64,56],[66,4,67,57]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査－2"]
[]
[]
[]
[null,null,null,null,"２．血液検査（最近の代表的なデータを記入してください。）"]
[]
[null,null,null,null,"検査結果報告書添付：",null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,"有",null,null,"必ず検査結果報告書を添付してください。\n検査結果報告書を添付する場合は、下欄への記入は不要です。"]
[]
[]
[null,null,null,null,"■（検査結果報告書添付「無」の場合）血液検査については、以下の項目を実施している場合は実施年月日及び検査結果を記入してください。"]
[]
[]
[null,null,null,null,null,null,"血液検査内容",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"実施年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査結果",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　　　　　　　　↑\nこのボタンをクリックすると、肝機能\n（AST）の「実施年月日」欄に入力した\n日付をタンデムマススクリーニング\n検査までの全ての項目に一括コピー\nできます。\n\n\n※検査実施年月日が異なる検査項目がある場合は、必ず個別に「実施年月日」欄を変更してください。"]
[]
[null,null,null,null,null,null,"肝機能",null,null,null,null,null,null,null,null,"ＡＳＴ（GOT） （IU/ℓ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ＡＬＴ（GPT） （IU/ℓ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ＬＤＨ（IU/ℓ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"アンモニア（μg/dℓ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ｐＨ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ｐＯ２（mmHg）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[null,null,null,null,null,null,"血液ガス分析"]
[]
[null,null,null,null,null,null,"（いずれかにレ点を記入）",null,null,null,null,null,null,null,null,"ｐＣＯ２（mmHg）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[null,null,null,null,null,null,null,null,null,null,"動脈"]
[]
[null,null,null,null,null,null,null,null,null,null,"静脈",null,null,null,null,"ＨＣＯ３－（mEq/ℓ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ＢＥ（mEq/ℓ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[]
[]
[null,null,null,null,null,null,"乳酸（mg/dℓ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[]
[]
[null,null,null,null,null,null,"ピルビン酸（mg/dℓ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・",null,null,null,null,"・"]
[null,null,null,null,null,null,null,null,"タンデムマススクリーニング検査",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"異常なし",null,null,null,null,null,null,"異常あり"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"検査を実施している",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,"＊異常ありの場合は、以下にその検査結果を記入してください。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"検査を実施していない"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"不明"]
[]
[]
[]
[null,null,null,null,null,"＊上記の検査項目のうち一項目でも実施していない場合は、以下にその理由を記入してください。"]
[]
[]
[null,null,null,null,null,null,null,null,null,"代謝異常を疑うような身体所見を認めなかったため"]
[]
[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,"３．上記の検査以外に実施した検査"]
[]
[null,null,null,null,"■上記以外に実施した検査がある場合は、検査の実施年月日と検査結果を記入してください。\n　例：ＦＩＳＨ解析、ＣＧＨマイクロアレイ解析、尿中有機酸分析、アミノ酸分析、クレアチニンキナーゼ\n　　（ＣＫ）、アイソザイム、血清銅、脳波、頭部エコー、聴性脳幹反応等"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,6]
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{"sheet":"P7 所見-1","index":8,"n_rows":116,"n_cols":58,"rows_kept":116,"cut":false,"hidden":false,"merged":[[8,8,9,54],[28,6,31,56],[24,5,27,56],[0,52,1,57],[2,4,4,57],[6,8,7,35],[6,36,7,38],[6,39,7,41],[6,42,7,43],[6,44,7,46],[6,47,7,48],[6,49,7,51],[6,52,7,53],[14,39,15,40],[14,41,15,44],[14,45,15,45],[14,46,15,56],[14,57,15,57],[16,5,19,56],[10,4,11,57],[12,5,13,57],[14,5,15,6],[14,7,15,9],[14,10,15,11],[14,12,15,24],[14,25,15,26],[14,27,15,31],[14,32,15,33],[14,34,15,38],[34,33,35,36],[34,45,35,51],[34,52,35,56],[34,38,35,43],[34,57,35,57],[36,5,41,56],[20,6,23,56],[32,5,33,57],[34,7,35,11],[34,14,35,17],[34,20,35,23],[34,24,35,24],[34,26,35,27],[34,29,35,30],[58,47,60,48],[42,6,45,56],[47,5,48,57],[49,6,50,16],[49,17,50,36],[49,37,50,56],[51,6,53,16],[51,24,53,25],[51,29,53,30],[51,44,53,45],[51,49,53,50],[61,17,63,18],[61,19,63,21],[61,22,63,23],[61,24,63,26],[61,27,63,28],[61,29,63,31],[58,34,60,36],[58,37,60,38],[54,6,55,56],[56,7,57,55],[58,6,60,16],[58,17,60,18],[58,19,60,21],[58,22,60,23],[58,24,60,26],[58,27,60,28],[58,29,60,31],[58,32,60,33],[58,49,60,51],[58,52,60,53],[58,54,60,56],[58,39,60,41],[58,42,60,43],[58,44,60,46],[61,47,63,48],[61,49,63,51],[61,52,63,53],[61,54,63,56],[64,6,66,16],[64,17,66,18],[64,19,66,21],[64,22,66,23],[64,24,66,26],[64,27,66,28],[61,32,63,33],[61,34,63,36],[61,37,63,38],[61,39,63,41],[61,42,63,43],[61,44,63,46],[64,44,66,46],[64,47,66,48],[64,49,66,51],[64,52,66,53],[64,54,66,56],[64,39,66,41],[64,42,66,43],[61,6,63,16],[67,6,69,16],[67,17,69,18],[67,19,69,21],[67,22,69,23],[67,24,69,26],[64,29,66,31],[64,32,66,33],[64,34,66,36],[64,37,66,38],[83,4,84,57],[84,71,85,96],[77,5,78,57],[79,7,80,8],[79,11,80,12],[79,13,80,15],[79,17,79,56],[80,17,82,56],[71,5,72,57],[73,7,74,8],[73,11,74,12],[73,13,74,15],[73,17,73,56],[74,17,76,56],[67,42,69,43],[67,44,69,46],[67,47,69,48],[67,49,69,51],[67,52,69,53],[67,54,69,56],[67,27,69,28],[67,29,69,31],[67,32,69,33],[67,34,69,36],[67,37,69,38],[67,39,69,41]]}
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[]
[null,null,null,null,"脳性麻痺の状況及び所見"]
[]
[]
[]
[null,null,null,null,null,null,null,null,"脳性麻痺の状況及び所見の確認日＊　：　西暦",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,20,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日"]
[]
[null,null,null,null,null,null,null,null,"＊確認日は、原則、2025年以降の申請時点で診断してください（児が亡くなっている場合を除く）。"]
[]
[null,null,null,null,"１．神経学的所見、その他の機能障害の所見"]
[]
[null,null,null,null,null,"１）運動障害"]
[]
[null,null,null,null,null,null,null,"痙直",null,null,null,null,"アテトーゼ・不随意運動",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"運動失調",null,null,null,null,null,null,"低緊張",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,"＊低緊張型脳性麻痺の場合は、脳性であると考えられる所見・理由を記入してください。また、脊髄性または末梢神経障害、神経筋疾患（脊髄性筋萎縮症、筋ジストロフィー、先天性ミオパチー等）による運動障害ではないと考える所見・理由を記入してください。"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,"＊重度の知的障害 （精神発達遅滞） による運動発達遅滞が認められる場合は、上肢の動作・活動の状況について、具体的な所見（投げる、引っ張る等の動作の可否や食事の動作等）を記入してください。"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,"２）麻痺部位"]
[]
[null,null,null,null,null,null,null,"四肢麻痺",null,null,null,null,null,null,"両麻痺",null,null,null,null,null,"片麻痺",null,null,null,"（",null,"右",null,null,"左）",null,null,null,"対麻痺",null,null,null,null,"三肢麻痺",null,null,null,null,null,null,"単麻痺（部位：",null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,null,null,null,null,"＊片麻痺の場合は、動作・活動の状況について、左右差の程度や患側の機能程度（補助肢として使用可能か否か等）の具体的な状況を記入してください。また、上肢のみの障害で給付申請を行う場合は、食事動作（スプーンを口に運ぶ、コップを手で持って口に運ぶ等の動作の可否）について具体的な状況を記入してください。"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,"３）反射異常（いずれかにレ点を記入してください）"]
[]
[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,null,null,null,null,null,null,null,"左"]
[]
[null,null,null,null,null,null,"バビンスキー反射",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,"有",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,"有"]
[]
[]
[null,null,null,null,null,null,"＊バビンスキー反射の検査が困難な場合は、他の病的反射の所見を記入してください。"]
[]
[]
[]
[null,null,null,null,null,null,"上腕二頭筋反射",null,null,null,null,null,null,null,null,null,null,null,null,"消失",null,null,null,null,"減弱",null,null,null,null,"正常",null,null,null,null,"亢進",null,null,null,null,"消失",null,null,null,null,"減弱",null,null,null,null,"正常",null,null,null,null,"亢進"]
[]
[]
[null,null,null,null,null,null,"上腕三頭筋反射",null,null,null,null,null,null,null,null,null,null,null,null,"消失",null,null,null,null,"減弱",null,null,null,null,"正常",null,null,null,null,"亢進",null,null,null,null,"消失",null,null,null,null,"減弱",null,null,null,null,"正常",null,null,null,null,"亢進"]
[]
[]
[null,null,null,null,null,null,"膝蓋腱反射",null,null,null,null,null,null,null,null,null,null,null,null,"消失",null,null,null,null,"減弱",null,null,null,null,"正常",null,null,null,null,"亢進",null,null,null,null,"消失",null,null,null,null,"減弱",null,null,null,null,"正常",null,null,null,null,"亢進"]
[]
[]
[null,null,null,null,null,null,"アキレス腱反射",null,null,null,null,null,null,null,null,null,null,null,null,"消失",null,null,null,null,"減弱",null,null,null,null,"正常",null,null,null,null,"亢進",null,null,null,null,"消失",null,null,null,null,"減弱",null,null,null,null,"正常",null,null,null,null,"亢進"]
[]
[]
[]
[null,null,null,null,null,"４）姿勢異常"]
[]
[null,null,null,null,null,null,null,"無",null,null,null,"有",null,"➡",null,null,null,"部位・所見（例：強い反り返り、下肢交叉、尖足等）"]
[]
[]
[]
[null,null,null,null,null,"５）関節拘縮"]
[]
[null,null,null,null,null,null,null,"無",null,null,null,"有",null,"➡",null,null,null,"部位・所見（例：股関節、膝関節、足関節等）"]
[]
[]
[]
[null,null,null,null,7]
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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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所見－2"]
[]
[]
[null,null,null,null,"２．動作・活動の状況及び所見（可能－○　不可能－×を記入）"]
[]
[]
[null,null,null,null,"■各項目について、動作・活動が完全にできる場合は「○」、動作・活動が完全にできない場合（部分的にできる場合も含む）は「×」のいずれかを記入してください。"]
[]
[]
[null,null,null,null,"■なお、明らかにできると判断される項目については、実際に動作の確認を行わず「○」とすることもできます。"]
[]
[]
[]
[null,null,null,null,null,"１）下肢・体幹運動に関する項目"]
[]
[null,null,null,null,null,null,"№",null,null,"項　　　　　目",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"判定\n○/×"]
[]
[]
[null,null,null,null,null,null,1,null,null,"頚がすわる（坐位で胸部を支えてもらって、頭を真っ直ぐに上げ３秒以上保持できる）"]
[]
[null,null,null,null,null,null,2,null,null,"横向きに半分寝返りをする（臀部と肩甲骨のいずれもが、床面から離れる）",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,"　　　　　　　　　↑\nこのボタンをクリックすると、\n下肢・体幹運動に関する項目の「判定」欄が全て×となります。\n\n※○の項目がある場合は、このボタンをクリックした後、必ず当該項目の「判定」欄を○に変更してください。"]
[]
[null,null,null,null,null,null,3,null,null,"寝返りをする（背臥位から腹臥位へ、左右いずれかの一方ができれば可）"]
[]
[null,null,null,null,null,null,4,null,null,"腹臥位で頭部を垂直に挙上できる（３秒以上）"]
[]
[null,null,null,null,null,null,5,null,null,"床の上で、後方から腰を支えると坐位を保持できる（腰部を両手で軽く支えてやると、手をつかずに、坐位を５秒以上保持できる）"]
[]
[]
[null,null,null,null,null,null,6,null,null,"肘這いをする（腹部が床につき、上肢を使って移動する）"]
[]
[null,null,null,null,null,null,7,null,null,"介助して坐らせると、床に手をつけ、ひとりで坐る（５秒以上保持できる）"]
[]
[null,null,null,null,null,null,8,null,null,"介助して坐らせると、手をつかずに、ひとりで坐る（３秒以上）"]
[]
[null,null,null,null,null,null,9,null,null,"自分で、臥位から坐位へ起き上がる"]
[]
[null,null,null,null,null,null,10,null,null,"手をつかずに、ひとりで坐って、45度後方の玩具に手を伸ばせる"]
[]
[null,null,null,null,null,null,11,null,null,"四つ這いをするが、下肢を交互に動かさず、バニーホップやシャフリング（いざり這い）をする"]
[]
[]
[null,null,null,null,null,null,12,null,null,"机等につかまって立ち上がれる"]
[]
[null,null,null,null,null,null,13,null,null,"下肢を交互に動かして、四つ這いをする"]
[]
[null,null,null,null,null,null,14,null,null,"机またはテーブル等や手すり等につかまって、伝い歩きができる（５歩以上）"]
[]
[null,null,null,null,null,null,15,null,null,"歩行補助具（杖、歩行器）を使って、移動するが、方向転換時に介助を要する"]
[]
[null,null,null,null,null,null,16,null,null,"歩行補助具を使って、介助なしに移動する"]
[]
[null,null,null,null,null,null,17,null,null,"介助があれば、階段を上がれる"]
[]
[null,null,null,null,null,null,18,null,null,"下肢装具をつけずに、支持なしで、立位を保持できる（３秒以上）"]
[]
[null,null,null,null,null,null,19,null,null,"下肢装具をつけずに、支持なしで、10歩、歩ける"]
[]
[null,null,null,null,null,null,20,null,null,"下肢装具をつけずに、10歩、歩いて停止し、転ばずにもと居た場所に戻ってくる"]
[]
[null,null,null,null,null,null,21,null,null,"床から立ち上がり立位をとる"]
[]
[null,null,null,null,null,null,22,null,null,"手すりを使って、４段、階段を上がれる（同じ段に足をそろえずに）"]
[]
[null,null,null,null,null,null,23,null,null,"手すりを使わずに、４段、階段を上がれる（同じ段に足をそろえずに）"]
[]
[]
[null,null,null,null,null,"２）　「下肢・体幹運動に関する項目」についての備考欄\n　　（上記項目の判定に関し特記事項がない場合は、本欄の記入は不要です。）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,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,null,null,null,null,null,null,null,null,null,null,"○"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"×"]

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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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所見－3"]
[]
[null,null,null,null,null,"３）上肢運動に関する項目"]
[]
[null,null,null,null,null,null,"№",null,null,"項　　　　　目",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"判定\n○/×"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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",null,null,null,null,null,"左",null,null,null,null,null,null,null,null,"　　　　　　　　　↑\nこのボタンをクリックすると、\n上肢運動に関する項目の\n「判定」欄が全て×となります。\n\n※○の項目がある場合は、このボタンをクリックした後、必ず当該項目の「判定」欄を○に変更してください。"]
[]
[null,null,null,null,null,null,1,null,null,"手にふれたものをつかむ（明らかな反射は除く）"]
[]
[null,null,null,null,null,null,2,null,null,"手を口に持っていく"]
[]
[null,null,null,null,null,null,3,null,null,"手を開くことができる"]
[]
[null,null,null,null,null,null,4,null,null,"玩具等を少しの間、握って遊ぶ"]
[]
[null,null,null,null,null,null,5,null,null,"顔に掛けたハンカチをとる"]
[]
[null,null,null,null,null,null,6,null,null,"近くのものを手を伸ばしてつかむ"]
[]
[null,null,null,null,null,null,7,null,null,"玩具等を持ちかえる"]
[]
[null,null,null,null,null,null,8,null,null,"哺乳瓶またはコップ等を自分で持てる"]
[]
[null,null,null,null,null,null,9,null,null,"小さなもの（乳児向けボーロ等）を親指と人差し指の指先でつまむ"]
[]
[null,null,null,null,null,null,10,null,null,"スプーンが持てる（３秒以上）"]
[]
[null,null,null,null,null,null,11,null,null,"リモコンのボタンを押せる"]
[]
[null,null,null,null,null,null,12,null,null,"知っているものを見て指でさす"]
[]
[null,null,null,null,null,null,13,null,null,"なぐり書きをする"]
[]
[null,null,null,null,null,null,14,null,null,"積み木を1つ積める"]
[]
[null,null,null,null,null,null,15,null,null,"積み木を2つか3つ積める"]
[]
[null,null,null,null,null,null,16,null,null,"お箸が持てる"]
[]
[]
[null,null,null,null,null,"４）「上肢運動に関する項目」についての備考欄\n　　（上記項目の判定に関し特記事項がない場合は、本欄の記入は不要です）"]
[]
[]
[]
[]
[null,null,null,null,null,"５）診断時の姿勢や移動状況が確認できる全身の写真を貼付（10～11頁）（複数枚）または\n　動画を添付してください。坐位、臥位、車椅子移乗等の姿勢や動作の状況がわかるよう、\n　 できるだけ薄着の状態で撮影してください。"]
[]
[]
[]
[null,null,null,null,null,"　注１: 片麻痺や上肢のみの障害で給付申請を行うケースで、写真のみでは障害程度の判断が困難と考えられる場合は、歩行（階段\n　　　　昇降等）や上肢での動作の状況（握る、つかむ、物に手をのばすなどの動作や食事動作等）を撮影した動画を追加でお願い\n　　　　することがあります。\n　注２: 写真または動画は、医師が適切に選択したものとします。"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"上記のとおり診断する。あわせて頭部画像データ（フィルムも可）等を添付する。"]
[]
[null,null,null,null,null,null,"【診断書作成日】",null,null,null,null,null,null,null,null,"西暦",null,null,20,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日",null,"※診断書を最終的に仕上げた日を記入してください。"]
[]
[null,null,null,null,null,null,"※診断書内容に関し照会を行う場合がありますので、医療機関名および所在地を必ず記入してください（ゴム印でも可）。"]
[]
[null,null,null,null,null,null,"【医療機関名】"]
[]
[null,null,null,null,null,null,"【所在地】",null,null,null,null,"（〒",null,null,null,null,"－",null,null,null,null,null,"）"]
[]
[]
[]
[null,null,null,null,null,null,"【電話番号】"]
[]
[null,null,null,null,null,null,"【診断医】",null,null,null,null,null,"診療科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"科",null,null,null,"医師氏名",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,"※複数の医師で診断書を作成する場合は、代表者1名の氏名を記入してください。"]
[]
[null,null,null,null,null,null,"【診断医要件】",null,null,null,null,null,null,null,null,null,"身体障害者福祉法第15条指定医\n（肢体不自由）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"小児神経専門医",null,null,null,null,null,null,null,null,null,null,null,null,"神経内科専門医"]
[]
[]
[null,null,null,null,null,"＊本児が給付対象と認定された場合は、産科医療特別給付事業　実施要綱第十一条第２項に基づき、この専用診断書を特別給付事業が実施する集計および分析の資料の一部として利用させていただきます。"]
[]
[]
[null,null,null,null,"【写真、動画、検査データ、NICUサマリー等添付欄】　＞＞＞次頁に続きがあります。＞＞＞"]
[]
[null,null,null,null,9]
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[null,null,null,null,"写 真 貼 付 欄"]
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[null,null,null,null,"＊写真の裏面にも氏名・生年月日及び撮影年月日（または撮影時の年齢）を必ず記入してください。\n＊坐位、臥位、車椅子移乗等の姿勢や動作の状況がわかるよう、できるだけ薄着の状態で撮影してください。"]
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[null,null,null,null,"写 真 貼 付 欄"]
[]
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[null,null,null,null,"＊写真の裏面にも氏名・生年月日及び撮影年月日（または撮影時の年齢）を必ず記入してください。\n＊坐位、臥位、車椅子移乗等の姿勢や動作の状況がわかるよう、できるだけ薄着の状態で撮影してください。"]
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[null,null,null,null,11]

{"sheet":"P12 動画について","index":13,"n_rows":83,"n_cols":6,"rows_kept":83,"cut":false,"hidden":false,"merged":[[1,4,3,57],[82,4,83,57],[15,4,27,57],[5,5,7,18],[5,19,7,40],[8,5,10,18],[8,19,10,40],[11,5,13,18],[11,19,13,40]]}
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[null,null,null,null,"添付動画について"]
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[null,null,null,null,null,"氏名"]
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[null,null,null,null,null,"生年月日"]
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[null,null,null,null,null,"撮影年月日\n（または撮影時の年齢）"]
[]
[]
[]
[null,null,null,null,"【留意事項】\n\n○　動画はＤＶＤ、ＳＤカード等の記録媒体で、「児の氏名」、「撮影日」がわかるように提出\n　　してください。動作の抽出など編集をしていただく必要はございません。\n　　なお、提出いただいた記録媒体は返却いたしませんので、ご了承ください。\n○　動画を提出いただく場合は、専用診断書P10～11への写真貼付は不要です。\n○　動作・活動の状況は、脳性麻痺の型、麻痺部位、合併症などによる個人差も大きいため、\n　　審査委員会の審査を進めていく過程で、改めて動画の提出をお願いすることもございます\n　　のでご了承ください。"]
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[null,null,null,null,12]

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[null,null,null,null,"検査データ ・ ＮＩＣＵサマリー等　添付欄"]
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[null,null,null,null,"＊検査結果・所見等には実施年月日が記入されていることを事前にご確認ください。\n＊診療録、サマリー、紹介状等診療情報がある場合はこちらに添付してください。\n＊右上にホチキスで添付してください。"]
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[null,null,null,null,13]