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功能 #13604 » 健康署婦女乳房X光攝影檢查服務檢查紀錄結果表單.json

Laura Huang, 2026/09/21 上午08:36

 
{
"locale": "zh-tw",
"title": "健康署婦女乳房X光攝影檢查服務檢查紀錄結果表單",
"description": {
"default": "（114 年 1 月修訂）\n本檢查「由衛生福利部國民健康署運用菸品健康福利捐／公務預算補助」",
"zh-tw": "本檢查「由衛生福利部國民健康署運用菸品健康福利捐／公務預算補助」（114 年 1 月修訂）"
},
"completedHtml": "<h3>表單填寫完成</h3>",
"pages": [
{
"name": "exam_info",
"title": "檢查資訊",
"elements": [
{
"type": "radiogroup",
"name": "payment_method",
"title": "支付方式",
"isRequired": true,
"choices": [
{
"value": "preventive",
"text": "預防保健"
},
{
"value": "nhi",
"text": "健保醫療給付"
},
{
"value": "other_subsidy",
"text": "其他公務預算補助"
},
{
"value": "self_pay",
"text": "自費健康檢查"
},
{
"value": "other",
"text": "其他"
}
]
},
{
"type": "radiogroup",
"name": "screening_vehicle",
"title": "乳房攝影車篩檢",
"isRequired": true,
"choices": [
{
"value": "no",
"text": "否"
},
{
"value": "yes",
"text": "是"
}
],
"colCount": 2
},
{
"type": "panel",
"name": "screening_detail_panel",
"visibleIf": "{screening_vehicle} notempty",
"elements": [
{
"type": "text",
"name": "device_registration",
"title": "儀器登設字",
"isRequired": true,
"placeholder": "請輸入儀器登設字號"
},
{
"type": "text",
"name": "institution_name",
"startWithNewLine": false,
"title": "所屬單位院所名稱",
"isRequired": true,
"placeholder": "請輸入院所名稱"
},
{
"type": "text",
"name": "institution_code",
"title": "機構代碼",
"isRequired": true,
"placeholder": "請輸入機構代碼"
},
{
"type": "text",
"name": "vehicle_number",
"visibleIf": "{screening_vehicle} = 'yes'",
"startWithNewLine": false,
"title": "車號",
"isRequired": true,
"placeholder": "請輸入攝影車車號"
}
]
},
{
"type": "text",
"name": "medical_record_number",
"title": "病歷號",
"isRequired": true,
"placeholder": "請輸入病歷號"
}
]
},
{
"name": "basic_info",
"title": "個人基本資料",
"description": "（檢查婦女填寫）",
"elements": [
{
"type": "text",
"name": "patient_name",
"title": "姓名",
"isRequired": true,
"placeholder": "請輸入姓名"
},
{
"type": "text",
"name": "id_number",
"startWithNewLine": false,
"title": "身分證統一編號／統一證號（外籍）",
"isRequired": true,
"placeholder": "請輸入身分證字號或統一證號"
},
{
"type": "panel",
"name": "birth_date_panel",
"title": "出生日期",
"elements": [
{
"type": "text",
"name": "birth_year",
"title": "民國年",
"isRequired": true,
"inputType": "number",
"min": 1,
"max": 150,
"placeholder": "例：70"
},
{
"type": "dropdown",
"name": "birth_month",
"startWithNewLine": false,
"title": "月份",
"isRequired": true,
"choices": [
{
"value": "01",
"text": "1 月"
},
{
"value": "02",
"text": "2 月"
},
{
"value": "03",
"text": "3 月"
},
{
"value": "04",
"text": "4 月"
},
{
"value": "05",
"text": "5 月"
},
{
"value": "06",
"text": "6 月"
},
{
"value": "07",
"text": "7 月"
},
{
"value": "08",
"text": "8 月"
},
{
"value": "09",
"text": "9 月"
},
{
"value": "10",
"text": "10 月"
},
{
"value": "11",
"text": "11 月"
},
{
"value": "12",
"text": "12 月"
}
],
"placeholder": "請選擇月份"
},
{
"type": "dropdown",
"name": "birth_day",
"startWithNewLine": false,
"title": "日期",
"isRequired": true,
"choices": [
{
"value": "01",
"text": "1 日"
},
{
"value": "02",
"text": "2 日"
},
{
"value": "03",
"text": "3 日"
},
{
"value": "04",
"text": "4 日"
},
{
"value": "05",
"text": "5 日"
},
{
"value": "06",
"text": "6 日"
},
{
"value": "07",
"text": "7 日"
},
{
"value": "08",
"text": "8 日"
},
{
"value": "09",
"text": "9 日"
},
{
"value": "10",
"text": "10 日"
},
{
"value": "11",
"text": "11 日"
},
{
"value": "12",
"text": "12 日"
},
{
"value": "13",
"text": "13 日"
},
{
"value": "14",
"text": "14 日"
},
{
"value": "15",
"text": "15 日"
},
{
"value": "16",
"text": "16 日"
},
{
"value": "17",
"text": "17 日"
},
{
"value": "18",
"text": "18 日"
},
{
"value": "19",
"text": "19 日"
},
{
"value": "20",
"text": "20 日"
},
{
"value": "21",
"text": "21 日"
},
{
"value": "22",
"text": "22 日"
},
{
"value": "23",
"text": "23 日"
},
{
"value": "24",
"text": "24 日"
},
{
"value": "25",
"text": "25 日"
},
{
"value": "26",
"text": "26 日"
},
{
"value": "27",
"text": "27 日"
},
{
"value": "28",
"text": "28 日"
},
{
"value": "29",
"text": "29 日"
},
{
"value": "30",
"text": "30 日"
},
{
"value": "31",
"text": "31 日"
}
],
"placeholder": "請選擇日期"
}
]
},
{
"type": "panel",
"name": "contact_panel",
"title": "聯絡資訊",
"elements": [
{
"type": "text",
"name": "phone",
"title": "電話",
"placeholder": "例：(04)2332-3456"
},
{
"type": "text",
"name": "mobile",
"startWithNewLine": false,
"title": "手機",
"placeholder": "例：0912-345-678"
}
]
},
{
"type": "panel",
"name": "address_panel",
"title": "現居住地址",
"elements": [
{
"type": "text",
"name": "district_code",
"title": "鄉鎮市區代碼",
"placeholder": "四碼數字"
},
{
"type": "dropdown",
"name": "address_county",
"startWithNewLine": false,
"title": "縣市",
"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": "address_district",
"title": "鄉鎮市區",
"placeholder": "例：霧峰區"
},
{
"type": "text",
"name": "address_village",
"startWithNewLine": false,
"title": "村里",
"placeholder": "例：柳豐里"
},
{
"type": "text",
"name": "address_detail",
"title": "路街、段、巷弄、號樓",
"placeholder": "例：柳豐路 500 號"
}
]
},
{
"type": "radiogroup",
"name": "education",
"title": "教育程度",
"choices": [
{
"value": "none",
"text": "無"
},
{
"value": "elementary",
"text": "小學"
},
{
"value": "junior_high",
"text": "國（初）中"
},
{
"value": "senior_high",
"text": "高中／高職"
},
{
"value": "college",
"text": "專科、大學"
},
{
"value": "graduate",
"text": "研究所以上"
},
{
"value": "refused",
"text": "拒答"
}
],
"colCount": 4
},
{
"type": "panel",
"name": "body_info_panel",
"title": "其它資訊",
"elements": [
{
"type": "text",
"name": "height",
"title": "身高（公分）",
"inputType": "number",
"min": 0,
"placeholder": "例：160"
},
{
"type": "text",
"name": "weight",
"startWithNewLine": false,
"title": "體重（公斤）",
"inputType": "number",
"min": 0,
"placeholder": "例：55"
}
]
}
]
},
{
"name": "disease_family_history",
"title": "疾病史與家族史",
"description": "個案臨床資料（檢查婦女填寫）",
"elements": [
{
"type": "checkbox",
"name": "disease_history",
"title": "有無得過下列疾病？",
"isRequired": true,
"choices": [
{
"value": "benign",
"text": "乳房良性相關疾病"
},
{
"value": "breast_cancer",
"text": "乳癌"
},
{
"value": "other_cancer",
"text": "其他癌症"
}
],
"showNoneItem": true,
"noneText": "無"
},
{
"type": "text",
"name": "other_cancer_detail",
"visibleIf": "{disease_history} contains 'other_cancer'",
"title": "其他癌症說明",
"isRequired": true,
"placeholder": "請說明癌症名稱"
},
{
"type": "radiogroup",
"name": "family_history",
"title": "與您有血緣的家屬中，有無人得過乳癌？",
"isRequired": true,
"choices": [
{
"value": "yes",
"text": "有"
},
{
"value": "no",
"text": "無"
}
],
"colCount": 2
},
{
"type": "matrixdropdown",
"name": "family_history_detail",
"visibleIf": "{family_history} = 'yes'",
"title": "家族乳癌史（請填列各血緣關係資料）",
"columns": [
{
"name": "count",
"title": "罹患乳癌人數",
"cellType": "text",
"inputType": "number",
"min": 0,
"placeholder": "人數"
},
{
"name": "diagnosis_age",
"title": "確診時年齡（同類型填最小值）",
"cellType": "text",
"inputType": "number",
"min": 0,
"placeholder": "歲"
}
],
"rows": [
{
"value": "mother",
"text": "母親"
},
{
"value": "sister",
"text": "姊妹"
},
{
"value": "daughter",
"text": "女兒"
},
{
"value": "grandmother_paternal",
"text": "祖母"
},
{
"value": "grandmother_maternal",
"text": "外祖母"
}
]
}
]
},
{
"name": "menstrual_birth_history",
"title": "月經與生育史",
"elements": [
{
"type": "panel",
"name": "menstrual_panel",
"title": "月經史",
"elements": [
{
"type": "radiogroup",
"name": "menarche_type",
"title": "初經年齡",
"isRequired": true,
"choices": [
{
"value": "age",
"text": "填寫年齡"
},
{
"value": "other",
"text": "其他，無法填寫初經年齡"
}
]
},
{
"type": "text",
"name": "menarche_age",
"visibleIf": "{menarche_type} = 'age'",
"title": "初經年齡（實歲）",
"isRequired": true,
"inputType": "number",
"min": 0,
"placeholder": "請輸入歲數"
},
{
"type": "text",
"name": "menarche_other_reason",
"visibleIf": "{menarche_type} = 'other'",
"title": "無法填寫初經年齡原因",
"isRequired": true,
"placeholder": "請說明原因"
},
{
"type": "radiogroup",
"name": "menopause",
"title": "是否已停經？",
"isRequired": true,
"choices": [
{
"value": "yes",
"text": "是"
},
{
"value": "no",
"text": "否"
}
],
"colCount": 2
},
{
"type": "text",
"name": "menopause_age",
"visibleIf": "{menopause} = 'yes'",
"title": "停經年齡（實歲）",
"isRequired": true,
"inputType": "number",
"min": 0,
"placeholder": "請輸入歲數"
},
{
"type": "radiogroup",
"name": "menopause_reason",
"visibleIf": "{menopause} = 'yes'",
"title": "停經原因",
"isRequired": true,
"choices": [
{
"value": "natural",
"text": "自然停經"
},
{
"value": "hysterectomy",
"text": "子宮切除"
},
{
"value": "oophorectomy",
"text": "卵巢切除"
},
{
"value": "other",
"text": "其他"
}
]
},
{
"type": "text",
"name": "menopause_reason_other",
"visibleIf": "{menopause_reason} = 'other'",
"title": "其他停經原因說明",
"isRequired": true,
"placeholder": "請說明停經原因"
}
]
},
{
"type": "panel",
"name": "birth_history_panel",
"title": "生育史",
"elements": [
{
"type": "text",
"name": "birth_count",
"title": "生產次數",
"isRequired": true,
"inputType": "number",
"min": 0,
"placeholder": "次"
},
{
"type": "radiogroup",
"name": "breastfeeding",
"title": "有無哺餵母乳（至少某胎哺餵母乳一個月以上）",
"isRequired": true,
"choices": [
{
"value": "yes",
"text": "有"
},
{
"value": "no",
"text": "無"
}
],
"colCount": 2
},
{
"type": "text",
"name": "first_birth_age",
"title": "第一胎生產實足年齡",
"inputType": "number",
"min": 0,
"placeholder": "歲"
}
]
}
]
},
{
"name": "medication_breast_exam",
"title": "用藥史與乳房檢查",
"elements": [
{
"type": "panel",
"name": "medication_panel",
"title": "用藥史",
"elements": [
{
"type": "radiogroup",
"name": "hormone_supplement",
"title": "是否服用荷爾蒙補充劑？",
"isRequired": true,
"choices": [
{
"value": "yes",
"text": "是"
},
{
"value": "no",
"text": "否"
}
],
"colCount": 2
},
{
"type": "text",
"name": "hormone_start_age",
"visibleIf": "{hormone_supplement} = 'yes'",
"title": "荷爾蒙補充劑開始服用年齡",
"isRequired": true,
"inputType": "number",
"min": 0,
"placeholder": "歲開始"
},
{
"type": "text",
"name": "hormone_duration",
"visibleIf": "{hormone_supplement} = 'yes'",
"startWithNewLine": false,
"title": "荷爾蒙補充劑服用年數",
"isRequired": true,
"inputType": "number",
"min": 0,
"placeholder": "年"
},
{
"type": "radiogroup",
"name": "contraceptive",
"title": "是否服用口服避孕藥？",
"isRequired": true,
"choices": [
{
"value": "yes",
"text": "是"
},
{
"value": "no",
"text": "否"
}
],
"colCount": 2
},
{
"type": "text",
"name": "contraceptive_start_age",
"visibleIf": "{contraceptive} = 'yes'",
"title": "口服避孕藥開始服用年齡",
"isRequired": true,
"inputType": "number",
"min": 0,
"placeholder": "歲開始"
},
{
"type": "text",
"name": "contraceptive_duration",
"visibleIf": "{contraceptive} = 'yes'",
"startWithNewLine": false,
"title": "口服避孕藥服用年數",
"isRequired": true,
"inputType": "number",
"min": 0,
"placeholder": "年"
}
]
},
{
"type": "radiogroup",
"name": "breast_lump",
"title": "是否有感覺到異常腫塊？",
"isRequired": true,
"choices": [
{
"value": "lump",
"text": "有摸到硬塊或疼痛、壓痛（請於下方示意圖直接標示位置）；"
},
{
"value": "none",
"text": "沒有症狀；"
},
{
"value": "never_checked",
"text": "未做過乳房自我檢查。"
}
]
},
{
"type": "panel",
"name": "breast_lump_position_panel",
"visibleIf": "{breast_lump} = 'lump'",
"title": "異常位置圖示標示與文字說明",
"elements": [
{
"type": "signaturepad",
"name": "breast_lump_diagram_mark",
"title": "請直接在乳房解剖示意圖上劃記「X」標示硬塊或疼痛位置：",
"isRequired": true,
"signatureWidth": 500,
"signatureHeight": 250,
"placeholder": "",
"backgroundImage": "data:image/svg+xml;utf8,<svg xmlns='http://www.w3.org/2000/svg' viewBox='0 0 500 250' width='500' height='250'><rect width='500' height='250' fill='%23f8fafc' rx='8' stroke='%23cbd5e1' stroke-width='1'/><g stroke='%23475569' stroke-width='2.5' fill='none'><path d='M 40 40 C 40 160, 200 160, 200 40'/><circle cx='120' cy='100' r='3' fill='%2364748b'/><text x='120' y='195' font-size='16' font-weight='bold' fill='%23334155' text-anchor='middle' stroke='none'>右乳 (Right)</text><path d='M 300 40 C 300 160, 460 160, 460 40'/><circle cx='380' cy='100' r='3' fill='%2364748b'/><text x='380' y='195' font-size='16' font-weight='bold' fill='%23334155' text-anchor='middle' stroke='none'>左乳 (Left)</text></g></svg>"
}
]
},
{
"type": "checkbox",
"name": "recent_exams",
"title": "最近二年內是否曾做過下列檢查（可複選）？",
"isRequired": true,
"choices": [
{
"value": "palpation",
"text": "醫護人員觸診"
},
{
"value": "mammography",
"text": "乳房攝影X光檢查"
},
{
"value": "ultrasound",
"text": "乳房超音波檢查"
}
],
"showNoneItem": true,
"noneText": "以上皆未做過"
},
{
"type": "radiogroup",
"name": "breast_surgery",
"title": "是否曾接受過乳房手術？",
"isRequired": true,
"choices": [
{
"value": "yes",
"text": "是"
},
{
"value": "no",
"text": "否"
}
],
"colCount": 2
},
{
"type": "checkbox",
"name": "breast_surgery_side",
"visibleIf": "{breast_surgery} = 'yes'",
"title": "手術側別",
"isRequired": true,
"choices": [
{
"value": "left",
"text": "左側"
},
{
"value": "right",
"text": "右側"
}
],
"colCount": 2
}
]
},
{
"name": "patient_confirmation",
"title": "受檢者確認",
"elements": [
{
"type": "html",
"name": "consent_statement",
"html": "<div style='background:#f8f9fa; padding:12px 16px; border-radius:6px; font-size:14px; line-height:1.8;'><p><strong>1.</strong> 本表資料將會作為衛生及學術單位進行個案追蹤關懷及健康管理、資格檢核、比對連結、統計分析、或政策評估等目的使用。受檢者同意受檢及資料利用。</p><p style='margin-top:8px;'><strong>2.</strong> 乳房 X 光攝影經證實可發現早期乳癌，但準確度並非 100%，約有 15% 的乳癌無法有效偵測，所以即使檢查結果正常，在下次定期檢查前，如有發現異狀，仍應儘速就醫。</p></div>"
},
{
"type": "text",
"name": "data_confirm_signature",
"title": "＊確認以上資料正確無誤",
"isRequired": true,
"placeholder": "請輸入姓名確認"
},
{
"type": "html",
"name": "imaging_consent_statement",
"html": "<p style='font-size:14px; line-height:1.6; color:#333;'>＊為提升影像判讀準確性，本人同意相關醫事人員可於看診或判讀報告時查詢本人歷次篩檢報告及影像。</p>"
},
{
"type": "text",
"name": "patient_signature",
"title": "受檢婦女簽名",
"isRequired": true,
"placeholder": "請輸入姓名"
}
]
},
{
"name": "xray_result",
"title": "攝影檢查結果",
"description": "乳房X光攝影檢查結果（攝影醫院填寫）",
"elements": [
{
"type": "text",
"name": "hospital_name",
"title": "醫院名稱",
"defaultValue": "亞洲大學附屬醫院",
"isRequired": true,
"placeholder": "請輸入醫院名稱"
},
{
"type": "text",
"name": "hospital_code",
"startWithNewLine": false,
"title": "醫事機構代碼",
"defaultValue": "1303180011",
"isRequired": true,
"placeholder": "請輸入機構代碼"
},
{
"type": "panel",
"name": "xray_date_panel",
"title": "攝影日期",
"elements": [
{
"type": "text",
"name": "xray_date_year",
"title": "民國年",
"isRequired": true,
"inputType": "number",
"min": 1,
"max": 150,
"placeholder": "例：114"
},
{
"type": "dropdown",
"name": "xray_date_month",
"startWithNewLine": false,
"title": "月份",
"isRequired": true,
"choices": [
{
"value": "01",
"text": "1 月"
},
{
"value": "02",
"text": "2 月"
},
{
"value": "03",
"text": "3 月"
},
{
"value": "04",
"text": "4 月"
},
{
"value": "05",
"text": "5 月"
},
{
"value": "06",
"text": "6 月"
},
{
"value": "07",
"text": "7 月"
},
{
"value": "08",
"text": "8 月"
},
{
"value": "09",
"text": "9 月"
},
{
"value": "10",
"text": "10 月"
},
{
"value": "11",
"text": "11 月"
},
{
"value": "12",
"text": "12 月"
}
],
"placeholder": "請選擇月份"
},
{
"type": "dropdown",
"name": "xray_date_day",
"startWithNewLine": false,
"title": "日期",
"isRequired": true,
"choices": [
{
"value": "01",
"text": "1 日"
},
{
"value": "02",
"text": "2 日"
},
{
"value": "03",
"text": "3 日"
},
{
"value": "04",
"text": "4 日"
},
{
"value": "05",
"text": "5 日"
},
{
"value": "06",
"text": "6 日"
},
{
"value": "07",
"text": "7 日"
},
{
"value": "08",
"text": "8 日"
},
{
"value": "09",
"text": "9 日"
},
{
"value": "10",
"text": "10 日"
},
{
"value": "11",
"text": "11 日"
},
{
"value": "12",
"text": "12 日"
},
{
"value": "13",
"text": "13 日"
},
{
"value": "14",
"text": "14 日"
},
{
"value": "15",
"text": "15 日"
},
{
"value": "16",
"text": "16 日"
},
{
"value": "17",
"text": "17 日"
},
{
"value": "18",
"text": "18 日"
},
{
"value": "19",
"text": "19 日"
},
{
"value": "20",
"text": "20 日"
},
{
"value": "21",
"text": "21 日"
},
{
"value": "22",
"text": "22 日"
},
{
"value": "23",
"text": "23 日"
},
{
"value": "24",
"text": "24 日"
},
{
"value": "25",
"text": "25 日"
},
{
"value": "26",
"text": "26 日"
},
{
"value": "27",
"text": "27 日"
},
{
"value": "28",
"text": "28 日"
},
{
"value": "29",
"text": "29 日"
},
{
"value": "30",
"text": "30 日"
},
{
"value": "31",
"text": "31 日"
}
],
"placeholder": "請選擇日期"
}
]
},
{
"type": "radiogroup",
"name": "device_type",
"title": "攝影儀機型",
"isRequired": true,
"choices": [
{
"value": "CR",
"text": "CR 乳房X光攝影儀（Computed Radiography, CR）"
},
{
"value": "DR",
"text": "DR 乳房X光攝影儀（Digital Radiography, DR）"
},
{
"value": "Tomo",
"text": "乳房斷層攝影機（Tomosynthesis, Tomo）"
}
]
},
{
"type": "radiogroup",
"name": "palpation",
"title": "乳房觸診檢查",
"isRequired": true,
"choices": [
{
"value": "abnormal",
"text": "有腫塊或其他異常（請於下方示意圖直接標示位置）；"
},
{
"value": "normal",
"text": "無異常；"
},
{
"value": "not_done",
"text": "未做觸診檢查。"
}
]
},
{
"type": "panel",
"name": "palpation_position_panel",
"visibleIf": "{palpation} = 'abnormal'",
"title": "觸診異常位置圖示標示與文字說明",
"elements": [
{
"type": "signaturepad",
"name": "palpation_diagram_mark",
"title": "請直接在乳房解剖示意圖上劃記「X」標示腫塊或異常位置：",
"isRequired": true,
"signatureWidth": 500,
"signatureHeight": 250,
"placeholder": "",
"backgroundImage": "data:image/svg+xml;utf8,<svg xmlns='http://www.w3.org/2000/svg' viewBox='0 0 500 250' width='500' height='250'><rect width='500' height='250' fill='%23f8fafc' rx='8' stroke='%23cbd5e1' stroke-width='1'/><g stroke='%23475569' stroke-width='2.5' fill='none'><path d='M 40 40 C 40 160, 200 160, 200 40'/><circle cx='120' cy='100' r='3' fill='%2364748b'/><text x='120' y='195' font-size='16' font-weight='bold' fill='%23334155' text-anchor='middle' stroke='none'>右乳 (Right)</text><path d='M 300 40 C 300 160, 460 160, 460 40'/><circle cx='380' cy='100' r='3' fill='%2364748b'/><text x='380' y='195' font-size='16' font-weight='bold' fill='%23334155' text-anchor='middle' stroke='none'>左乳 (Left)</text></g></svg>"
}
]
},
{
"type": "radiogroup",
"name": "breast_density",
"title": "乳腺組成",
"isRequired": true,
"choices": [
{
"value": "fatty",
"text": "Fatty breast"
},
{
"value": "scattered",
"text": "Scattered fibroglandular density"
},
{
"value": "heterogeneous",
"text": "Heterogeneously dense"
},
{
"value": "extreme",
"text": "Extremely dense"
}
]
},
{
"type": "radiogroup",
"name": "old_film_comparison",
"title": "與舊片比較",
"isRequired": true,
"choices": [
{
"value": "yes",
"text": "是"
},
{
"value": "no",
"text": "否"
}
],
"colCount": 2
},
{
"type": "checkbox",
"name": "old_film_no_reason",
"visibleIf": "{old_film_comparison} = 'no'",
"title": "無法與舊片比較之理由",
"isRequired": true,
"choices": [
{
"value": "first_time",
"text": "第一次篩檢"
},
{
"value": "unavailable",
"text": "無法取得舊片"
},
{
"value": "unknown",
"text": "無法獲知是否有舊片"
}
]
},
{
"type": "panel",
"name": "reading_date_panel",
"title": "攝影判讀日期",
"elements": [
{
"type": "text",
"name": "reading_date_year",
"title": "民國年",
"isRequired": true,
"inputType": "number",
"min": 1,
"max": 150,
"placeholder": "例：114"
},
{
"type": "dropdown",
"name": "reading_date_month",
"startWithNewLine": false,
"title": "月份",
"isRequired": true,
"choices": [
{
"value": "01",
"text": "1 月"
},
{
"value": "02",
"text": "2 月"
},
{
"value": "03",
"text": "3 月"
},
{
"value": "04",
"text": "4 月"
},
{
"value": "05",
"text": "5 月"
},
{
"value": "06",
"text": "6 月"
},
{
"value": "07",
"text": "7 月"
},
{
"value": "08",
"text": "8 月"
},
{
"value": "09",
"text": "9 月"
},
{
"value": "10",
"text": "10 月"
},
{
"value": "11",
"text": "11 月"
},
{
"value": "12",
"text": "12 月"
}
],
"placeholder": "請選擇月份"
},
{
"type": "dropdown",
"name": "reading_date_day",
"startWithNewLine": false,
"title": "日期",
"isRequired": true,
"choices": [
{
"value": "01",
"text": "1 日"
},
{
"value": "02",
"text": "2 日"
},
{
"value": "03",
"text": "3 日"
},
{
"value": "04",
"text": "4 日"
},
{
"value": "05",
"text": "5 日"
},
{
"value": "06",
"text": "6 日"
},
{
"value": "07",
"text": "7 日"
},
{
"value": "08",
"text": "8 日"
},
{
"value": "09",
"text": "9 日"
},
{
"value": "10",
"text": "10 日"
},
{
"value": "11",
"text": "11 日"
},
{
"value": "12",
"text": "12 日"
},
{
"value": "13",
"text": "13 日"
},
{
"value": "14",
"text": "14 日"
},
{
"value": "15",
"text": "15 日"
},
{
"value": "16",
"text": "16 日"
},
{
"value": "17",
"text": "17 日"
},
{
"value": "18",
"text": "18 日"
},
{
"value": "19",
"text": "19 日"
},
{
"value": "20",
"text": "20 日"
},
{
"value": "21",
"text": "21 日"
},
{
"value": "22",
"text": "22 日"
},
{
"value": "23",
"text": "23 日"
},
{
"value": "24",
"text": "24 日"
},
{
"value": "25",
"text": "25 日"
},
{
"value": "26",
"text": "26 日"
},
{
"value": "27",
"text": "27 日"
},
{
"value": "28",
"text": "28 日"
},
{
"value": "29",
"text": "29 日"
},
{
"value": "30",
"text": "30 日"
},
{
"value": "31",
"text": "31 日"
}
],
"placeholder": "請選擇日期"
}
]
},
{
"type": "radiogroup",
"name": "xray_category",
"title": "攝影檢查結果",
"description": "※ Category 0, 3, 4, 5 需加填「乳房X光攝影檢查異常個案報告表」。",
"isRequired": true,
"choices": [
{
"value": "0",
"text": "（0）需附加其他影像檢查再評估（Category 0: Need Additional Imaging Evaluation.）"
},
{
"value": "1",
"text": "（1）無異常發現（Category 1: Negative.）"
},
{
"value": "2",
"text": "（2）良性發現（Category 2: Benign Finding）"
},
{
"value": "3",
"text": "（3）可能是良性發現－須短期追蹤檢查 6-12 個月（Category 3: Probably Benign Finding－Short Interval Follow-Up Suggested.）"
},
{
"value": "4",
"text": "（4）可疑異常須考慮組織生檢（Category 4: Suspicious Abnormality－Biopsy Should Be Considered.）"
},
{
"value": "5",
"text": "（5）高度懷疑為惡性腫瘤必須採取適當的措施（Category 5: Highly Suggestive of Malignancy－Appropriate Action Should Be Taken.）"
}
]
},
{
"type": "radiogroup",
"name": "category4_sub",
"visibleIf": "{xray_category} = '4'",
"title": "Category 4 子分類",
"isRequired": true,
"choices": [
{
"value": "a",
"text": "a. Low suspicion"
},
{
"value": "b",
"text": "b. Moderate suspicion"
},
{
"value": "c",
"text": "c. High suspicion"
}
]
},
{
"type": "text",
"name": "radiologist_name",
"title": "放射科醫師",
"isRequired": true,
"placeholder": "請輸入放射科醫師姓名"
},
{
"type": "text",
"name": "radiographer_name",
"startWithNewLine": false,
"title": "醫事放射師",
"isRequired": true,
"placeholder": "請輸入醫事放射師姓名"
}
]
}
],
"questionErrorLocation": "bottom",
"checkErrorsMode": "onComplete"
}
(2-2/2)