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功能 #13597 » 健康署婦女子宮頸抹片檢查服務檢查紀錄結果表單.json

survey js - Laura Huang, 2026/09/07 上午06:26

 
{
"locale": "zh-tw",
"title": "健康署婦女子宮頸抹片檢查服務檢查紀錄結果表單",
"description": "114 年 1 月修訂",
"logoPosition": "right",
"pages": [
{
"name": "step1_basic",
"title": "基本篩檢資訊",
"elements": [
{
"type": "radiogroup",
"name": "nationality",
"title": "國籍",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "本國"
},
{
"value": "2",
"text": "外籍人士"
}
],
"colCount": 2
},
{
"type": "dropdown",
"name": "mobile_screening",
"startWithNewLine": false,
"title": "抹片車或社區巡迴服務篩檢",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "否"
},
{
"value": "2",
"text": "抹片車"
},
{
"value": "3",
"text": "社區巡迴服務篩檢"
}
],
"placeholder": "請選擇"
},
{
"type": "dropdown",
"name": "q1_payment_method",
"startWithNewLine": false,
"title": "1. 支付方式",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "預防保健"
},
{
"value": "2",
"text": "健保醫療給付"
},
{
"value": "3",
"text": "其他公務預算補助"
},
{
"value": "4",
"text": "其他"
},
{
"value": "6",
"text": "自費健康檢查"
}
],
"placeholder": "請選擇"
},
{
"type": "radiogroup",
"name": "unsatisfactory_redo",
"title": "難判重做？",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "是"
},
{
"value": "2",
"text": "否"
}
],
"colCount": 2
},
{
"type": "text",
"name": "schedule_code",
"startWithNewLine": false,
"title": "時程代碼"
}
]
},
{
"name": "step2_personal",
"title": "一、個人基本資料",
"description": "檢查婦女填寫",
"elements": [
{
"type": "text",
"name": "q2_name",
"title": "2. 姓名",
"isRequired": true,
"placeholder": {
"zh-tw": "請輸入姓名"
}
},
{
"type": "text",
"name": "q4_id_number",
"startWithNewLine": false,
"title": "4. 身分證統一編號或統一證號(外籍)",
"isRequired": true,
"maxLength": 10,
"placeholder": {
"default": "10 碼",
"zh-tw": "請輸入正確的身分證字號"
}
},
{
"type": "panel",
"name": "q3_birthdate_panel",
"title": "3. 出生日期",
"elements": [
{
"type": "text",
"name": "q3_birth_year",
"title": "民國（年）",
"isRequired": true,
"inputType": "number",
"min": 1,
"max": 150,
"placeholder": "例：70"
},
{
"type": "dropdown",
"name": "q3_birth_month",
"startWithNewLine": false,
"title": "月份",
"isRequired": true,
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12"
],
"placeholder": "請選擇月份"
},
{
"type": "dropdown",
"name": "q3_birth_day",
"startWithNewLine": false,
"title": "日期",
"isRequired": true,
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12",
"13",
"14",
"15",
"16",
"17",
"18",
"19",
"20",
"21",
"22",
"23",
"24",
"25",
"26",
"27",
"28",
"29",
"30",
"31"
],
"placeholder": "請選擇日期"
}
]
},
{
"type": "text",
"name": "q5_phone",
"title": "5. 電話",
"isRequired": true,
"inputType": "tel",
"placeholder": {
"zh-tw": "請輸入電話號碼"
}
},
{
"type": "dropdown",
"name": "q6_education",
"startWithNewLine": false,
"title": "6. 教育程度",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "無"
},
{
"value": "2",
"text": "小學"
},
{
"value": "3",
"text": "國(初)中"
},
{
"value": "4",
"text": "高中、高職"
},
{
"value": "5",
"text": "專科、大學"
},
{
"value": "6",
"text": "研究所以上"
},
{
"value": "7",
"text": "拒答"
}
],
"placeholder": "請選擇"
},
{
"type": "panel",
"name": "q7_current_address_panel",
"title": "7. 現住址",
"elements": [
{
"type": "dropdown",
"name": "q7_county_city",
"title": "縣/市",
"isRequired": true,
"choices": [
"臺北市",
"新北市",
"桃園市",
"臺中市",
"臺南市",
"高雄市",
"基隆市",
"新竹市",
"嘉義市",
"新竹縣",
"苗栗縣",
"彰化縣",
"南投縣",
"雲林縣",
"嘉義縣",
"屏東縣",
"宜蘭縣",
"花蓮縣",
"臺東縣",
"澎湖縣",
"金門縣",
"連江縣"
],
"placeholder": "請選擇縣市"
},
{
"type": "text",
"name": "q7_district",
"startWithNewLine": false,
"title": "鄉鎮/市區",
"isRequired": true,
"placeholder": {
"zh-tw": "請輸入鄉鎮區域"
}
},
{
"type": "text",
"name": "q7_township_code",
"startWithNewLine": false,
"title": "鄉鎮代碼"
},
{
"type": "text",
"name": "q7_detail_address",
"title": "詳細地址（村/里、路街、段、巷、弄、號、樓）",
"placeholder": "例：中正里忠孝東路一段 100 巷 5 弄 3 號 2 樓"
}
]
},
{
"type": "panel",
"name": "q8_household_address_panel",
"title": "8. 戶籍住址",
"elements": [
{
"type": "dropdown",
"name": "q8_county_city",
"title": "縣/市",
"isRequired": true,
"choices": [
"臺北市",
"新北市",
"桃園市",
"臺中市",
"臺南市",
"高雄市",
"基隆市",
"新竹市",
"嘉義市",
"新竹縣",
"苗栗縣",
"彰化縣",
"南投縣",
"雲林縣",
"嘉義縣",
"屏東縣",
"宜蘭縣",
"花蓮縣",
"臺東縣",
"澎湖縣",
"金門縣",
"連江縣"
],
"placeholder": "請選擇縣市"
},
{
"type": "text",
"name": "q8_district",
"startWithNewLine": false,
"title": "鄉鎮/市區",
"isRequired": true,
"placeholder": {
"zh-tw": "請輸入鄉鎮區域"
}
},
{
"type": "text",
"name": "q8_township_code",
"startWithNewLine": false,
"title": "鄉鎮代碼"
}
]
}
]
},
{
"name": "step3_clinical",
"title": "二、個案臨床資料",
"description": "檢查婦女填寫",
"elements": [
{
"type": "dropdown",
"name": "q9_last_smear_time",
"title": "9. 最近一次抹片檢查時間",
"choices": [
{
"value": "1",
"text": "1 年內"
},
{
"value": "2",
"text": "1 至 2 年內"
},
{
"value": "3",
"text": "2 至 3 年內"
},
{
"value": "4",
"text": "3 年以上"
},
{
"value": "5",
"text": "從未檢查過"
}
],
"placeholder": "請選擇"
},
{
"type": "radiogroup",
"name": "q10_menopause",
"title": "10. 已停經？（一年無月經）",
"choices": [
{
"value": "1",
"text": "是"
},
{
"value": "2",
"text": "否"
},
{
"value": "3",
"text": "不知道"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "q12_pregnant",
"startWithNewLine": false,
"title": "12. 現在是否懷孕？",
"choices": [
{
"value": "1",
"text": "是"
},
{
"value": "2",
"text": "否"
},
{
"value": "3",
"text": "不知道"
}
],
"colCount": 3
},
{
"type": "panel",
"name": "q11_period_panel",
"title": "11. 最後一次月經日期",
"elements": [
{
"type": "text",
"name": "q11_period_year",
"title": "民國（年）",
"inputType": "number",
"min": 1,
"max": 150,
"placeholder": "例：114"
},
{
"type": "dropdown",
"name": "q11_period_month",
"startWithNewLine": false,
"title": "月份",
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12"
],
"placeholder": "請選擇月份"
},
{
"type": "dropdown",
"name": "q11_period_day",
"startWithNewLine": false,
"title": "日期",
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12",
"13",
"14",
"15",
"16",
"17",
"18",
"19",
"20",
"21",
"22",
"23",
"24",
"25",
"26",
"27",
"28",
"29",
"30",
"31"
],
"placeholder": "請選擇日期"
}
]
},
{
"type": "radiogroup",
"name": "q13_hysterectomy",
"title": "13. 子宮是否切除？",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "是"
},
{
"value": "2",
"text": "否"
},
{
"value": "3",
"text": "不知道"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "q14_radiation",
"startWithNewLine": false,
"title": "14. 是否接受過放射線治療？",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "是"
},
{
"value": "2",
"text": "否"
},
{
"value": "3",
"text": "不知道"
}
],
"colCount": 3
},
{
"type": "radiogroup",
"name": "q15_hpv_vaccine",
"title": "15. 是否曾接種 HPV 疫苗？",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "是"
},
{
"value": "2",
"text": "否"
},
{
"value": "3",
"text": "不知道"
}
],
"colCount": 3
},
{
"type": "text",
"name": "q15_hpv_vaccine_year",
"visibleIf": "{q15_hpv_vaccine} = '1'",
"startWithNewLine": false,
"title": "接種年份（民國年）",
"inputType": "number",
"min": 1,
"max": 150,
"placeholder": "例：110"
},
{
"type": "text",
"name": "consent_name",
"title": "本人同意接受檢查，確認以上資料正確無誤（請填寫姓名）",
"isRequired": true,
"placeholder": {
"zh-tw": "請輸入姓名"
}
}
]
},
{
"name": "step4_specimen",
"title": "三之一、抹片資料（採檢機構）",
"description": "採檢醫療機構填寫",
"elements": [
{
"type": "text",
"name": "q16_medical_record_number",
"title": "16. 病歷號"
},
{
"type": "radiogroup",
"name": "double_cervix",
"startWithNewLine": false,
"title": "雙子宮頸？",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "是"
},
{
"value": "2",
"text": "否"
}
],
"colCount": 2
},
{
"type": "panel",
"name": "q17_sampling_date_panel",
"title": "17. 抹片檢體取樣日期",
"elements": [
{
"type": "text",
"name": "q17_sampling_year",
"title": "民國（年）",
"isRequired": true,
"inputType": "number",
"min": 1,
"max": 150,
"placeholder": "例：114"
},
{
"type": "dropdown",
"name": "q17_sampling_month",
"startWithNewLine": false,
"title": "月份",
"isRequired": true,
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12"
],
"placeholder": "請選擇月份"
},
{
"type": "dropdown",
"name": "q17_sampling_day",
"startWithNewLine": false,
"title": "日期",
"isRequired": true,
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12",
"13",
"14",
"15",
"16",
"17",
"18",
"19",
"20",
"21",
"22",
"23",
"24",
"25",
"26",
"27",
"28",
"29",
"30",
"31"
],
"placeholder": "請選擇日期"
}
]
},
{
"type": "text",
"name": "q18_institution_name",
"title": "18. 取樣機構名稱",
"defaultValue": "亞洲大學附屬醫院",
"isRequired": true
},
{
"type": "text",
"name": "q18_institution_code",
"startWithNewLine": false,
"title": "代碼（10 碼）",
"defaultValue": "1303180011",
"isRequired": true,
"maxLength": 10
},
{
"type": "text",
"name": "q19_sampler_name",
"title": "19. 取樣醫事人員",
"isRequired": true
},
{
"type": "dropdown",
"name": "q19_sampler_role",
"startWithNewLine": false,
"title": "身分別",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "婦產科醫師"
},
{
"value": "2",
"text": "家醫科醫師"
},
{
"value": "3",
"text": "助產人員"
},
{
"value": "4",
"text": "衛生所護理人員"
},
{
"value": "5",
"text": "衛生所醫師（非屬婦產/家醫）"
}
],
"placeholder": "請選擇"
},
{
"type": "radiogroup",
"name": "q20_hpv_test",
"title": "20. 合併 HPV 檢測？",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "否"
},
{
"value": "2",
"text": "是"
}
],
"colCount": 2
},
{
"type": "dropdown",
"name": "q21_smear_purpose",
"startWithNewLine": false,
"title": "21. 做抹片目的",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "篩檢"
},
{
"value": "2",
"text": "懷疑癌症"
},
{
"value": "3",
"text": "追蹤"
},
{
"value": "4",
"text": "前次抹片難以判讀"
},
{
"value": "5",
"text": "其他"
}
],
"placeholder": "請選擇"
},
{
"type": "text",
"name": "q21_other_text",
"visibleIf": "{q21_smear_purpose} = '5'",
"startWithNewLine": false,
"title": "其他目的說明"
},
{
"type": "comment",
"name": "q22_clinical_findings",
"title": "22. 臨床所見（含骨盆腔檢查結果）",
"rows": 2
}
]
},
{
"name": "step5_pathology_info",
"title": "三之二、抹片資料（病理機構）",
"description": "病理醫療機構填寫",
"elements": [
{
"type": "text",
"name": "q23_pathology_number",
"title": "23. 抹片細胞病理編號",
"isRequired": true
},
{
"type": "text",
"name": "q24_institution_name",
"title": "24. 判讀機構名稱",
"isRequired": true
},
{
"type": "text",
"name": "q24_institution_code",
"startWithNewLine": false,
"title": "代碼（10 碼）",
"isRequired": true,
"maxLength": 10
},
{
"type": "panel",
"name": "q25_received_date_panel",
"title": "25. 抹片收到日期",
"elements": [
{
"type": "text",
"name": "q25_received_year",
"title": "民國（年）",
"isRequired": true,
"inputType": "number",
"min": 1,
"max": 150,
"placeholder": "例：114"
},
{
"type": "dropdown",
"name": "q25_received_month",
"startWithNewLine": false,
"title": "月份",
"isRequired": true,
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12"
],
"placeholder": "請選擇月份"
},
{
"type": "dropdown",
"name": "q25_received_day",
"startWithNewLine": false,
"title": "日期",
"isRequired": true,
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12",
"13",
"14",
"15",
"16",
"17",
"18",
"19",
"20",
"21",
"22",
"23",
"24",
"25",
"26",
"27",
"28",
"29",
"30",
"31"
],
"placeholder": "請選擇日期"
}
]
},
{
"type": "radiogroup",
"name": "q26_specimen_type",
"title": "26. 檢體種類",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "常規抹片"
},
{
"value": "2",
"text": "液體標本"
}
],
"colCount": 2
}
]
},
{
"name": "step6_results",
"title": "四、抹片判讀結果",
"description": "病理醫療機構填寫",
"elements": [
{
"type": "dropdown",
"name": "q27_reading_method",
"title": "27. 閱片方式",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "人工"
},
{
"value": "2",
"text": "機械"
},
{
"value": "3",
"text": "人工＋機械"
}
],
"placeholder": "請選擇"
},
{
"type": "dropdown",
"name": "q28_smear_quality",
"startWithNewLine": false,
"title": "28. 抹片品質",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "良好"
},
{
"value": "2",
"text": "尚可"
},
{
"value": "3",
"text": "抹片難以判讀"
}
],
"placeholder": "請選擇"
},
{
"type": "checkbox",
"name": "q29_unsatisfactory_reason",
"visibleIf": "{q28_smear_quality} = '2' or {q28_smear_quality} = '3'",
"title": "29. 尚可或難以判讀之原因（最多選二個）",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "抹片固定或保存不良"
},
{
"value": "2",
"text": "細胞太少"
},
{
"value": "3",
"text": "太厚或太多血液"
},
{
"value": "4",
"text": "沒有子宮內頸成份"
},
{
"value": "5",
"text": "炎症細胞過多"
},
{
"value": "6",
"text": "存在外來物（如潤滑劑）"
},
{
"value": "7",
"text": "過多細胞溶解或自溶"
},
{
"value": "8",
"text": "其他"
}
],
"colCount": 2,
"maxSelectedChoices": 2
},
{
"type": "text",
"name": "q29_other_text",
"visibleIf": "{q29_unsatisfactory_reason} contains '8'",
"title": "其他原因說明"
},
{
"type": "checkbox",
"name": "q30_infection",
"title": "30. 可能的感染（可多選）",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "Candida"
},
{
"value": "2",
"text": "Trichomonas"
},
{
"value": "3",
"text": "Herpes"
},
{
"value": "7",
"text": "Shift in flora (BV)"
},
{
"value": "8",
"text": "Actinomyces"
},
{
"value": "6",
"text": "Others"
}
],
"colCount": 3
},
{
"type": "text",
"name": "q30_other_text",
"visibleIf": "{q30_infection} contains '6'",
"title": "其他感染說明"
},
{
"type": "dropdown",
"name": "q31_diagnosis_category",
"title": "31. 細胞病理診斷 — 分類（只可單選）",
"isRequired": true,
"choices": [
{
"value": "negative",
"text": "Negative for intraepithelial lesion or malignancy"
},
{
"value": "asc",
"text": "Atypical squamous cells"
},
{
"value": "lsil",
"text": "Low-grade squamous intraepithelial lesion"
},
{
"value": "hsil",
"text": "High-grade squamous intraepithelial lesion"
},
{
"value": "11",
"text": "Squamous cell carcinoma"
},
{
"value": "agc",
"text": "Atypical glandular cells"
},
{
"value": "18",
"text": "Endocervical adenocarcinoma in situ"
},
{
"value": "12",
"text": "Adenocarcinoma"
},
{
"value": "13",
"text": "Other malignant neoplasm"
},
{
"value": "14",
"text": "Other"
},
{
"value": "17",
"text": "Dysplasia cannot exclude HSIL"
}
],
"placeholder": "請選擇分類"
},
{
"type": "dropdown",
"name": "q31_diagnosis_negative",
"visibleIf": "{q31_diagnosis_category} = 'negative'",
"startWithNewLine": false,
"title": "診斷細項",
"isRequired": true,
"choices": [
{
"value": "1",
"text": "Within normal limit"
},
{
"value": "2",
"text": "Reactive changes (Inflammation, repair, radiation, others)"
},
{
"value": "3",
"text": "Atrophy with inflammation"
}
],
"placeholder": "請選擇細項"
},
{
"type": "radiogroup",
"name": "q31_diagnosis_asc",
"visibleIf": "{q31_diagnosis_category} = 'asc'",
"startWithNewLine": false,
"title": "診斷細項",
"isRequired": true,
"choices": [
{
"value": "4",
"text": "ASC-US"
},
{
"value": "16",
"text": "ASC cannot exclude HSIL"
}
]
},
{
"type": "radiogroup",
"name": "q31_diagnosis_lsil",
"visibleIf": "{q31_diagnosis_category} = 'lsil'",
"startWithNewLine": false,
"title": "診斷細項",
"isRequired": true,
"choices": [
{
"value": "6",
"text": "Mild dysplasia (CIN1) with koilocytes"
},
{
"value": "7",
"text": "Mild dysplasia (CIN1) without koilocytes"
}
]
},
{
"type": "dropdown",
"name": "q31_diagnosis_hsil",
"visibleIf": "{q31_diagnosis_category} = 'hsil'",
"startWithNewLine": false,
"title": "診斷細項",
"isRequired": true,
"choices": [
{
"value": "8",
"text": "Moderate dysplasia (CIN2)"
},
{
"value": "9",
"text": "Severe dysplasia (CIN3)"
},
{
"value": "10",
"text": "Carcinoma in situ (CIN3)"
}
],
"placeholder": "請選擇細項"
},
{
"type": "radiogroup",
"name": "q31_diagnosis_agc",
"visibleIf": "{q31_diagnosis_category} = 'agc'",
"startWithNewLine": false,
"title": "診斷細項",
"isRequired": true,
"choices": [
{
"value": "5",
"text": "Atypical glandular cells"
},
{
"value": "15",
"text": "Atypical glandular cells favor neoplasm"
}
]
},
{
"type": "radiogroup",
"name": "q32_endometrial_cells",
"title": "32. 子宮內膜細胞出現於 40 歲以上婦女",
"choices": [
{
"value": "1",
"text": "是"
},
{
"value": "2",
"text": "否"
}
],
"colCount": 2
},
{
"type": "checkbox",
"name": "q33_suggestions",
"title": "33. 建議",
"choices": [
{
"value": "1",
"text": "因抹片難以判讀，請重做抹片檢查"
},
{
"value": "2",
"text": "治療發炎，並於三個月後重做抹片檢查"
},
{
"value": "3",
"text": "抹片結果異常，請再做進一步檢查"
},
{
"value": "4",
"text": "其他建議"
}
]
},
{
"type": "comment",
"name": "q33_other_suggestion_text",
"visibleIf": "{q33_suggestions} contains '4'",
"title": "其他建議內容",
"rows": 2
}
]
},
{
"name": "step7_examiner",
"title": "檢驗者資訊",
"elements": [
{
"type": "text",
"name": "cytotechnologist_name",
"title": "Cytotechnologist",
"isRequired": true
},
{
"type": "text",
"name": "cytotechnologist_code",
"startWithNewLine": false,
"title": "代碼",
"isRequired": true
},
{
"type": "text",
"name": "cytopathologist_name",
"title": "Cytopathologist",
"isRequired": true
},
{
"type": "text",
"name": "cytopathologist_code",
"startWithNewLine": false,
"title": "代碼",
"isRequired": true,
"requiredIf": "{cytopathologist_name} notempty"
},
{
"type": "panel",
"name": "report_date_panel",
"title": "報告日期",
"elements": [
{
"type": "dropdown",
"name": "report_month",
"title": "月份",
"isRequired": true,
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12"
],
"placeholder": "請選擇月份"
},
{
"type": "dropdown",
"name": "report_day",
"startWithNewLine": false,
"title": "日期",
"isRequired": true,
"choices": [
"1",
"2",
"3",
"4",
"5",
"6",
"7",
"8",
"9",
"10",
"11",
"12",
"13",
"14",
"15",
"16",
"17",
"18",
"19",
"20",
"21",
"22",
"23",
"24",
"25",
"26",
"27",
"28",
"29",
"30",
"31"
],
"placeholder": "請選擇日期"
}
]
},
{
"type": "text",
"name": "confirmed_diagnosis_date",
"title": "確診日期",
"isRequired": true,
"inputType": "date"
}
]
}
],
"questionErrorLocation": "bottom",
"showTOC": true,
"checkErrorsMode": "onComplete"
}
(2-2/2)