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<!DOCTYPE html>
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<html lang="zh-Hant">
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<head>
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<meta charset="UTF-8">
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<meta name="viewport" content="width=device-width, initial-scale=1.0">
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<title>健康署成人預防保健服務檢查紀錄結果表單</title>
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<style>
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* { margin: 0; padding: 0; box-sizing: border-box; }
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body {
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font-family: "Roboto", "Microsoft JhengHei", "微軟正黑體", "PingFang TC", sans-serif;
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font-size: 14px;
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line-height: 1.5;
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color: #364153;
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background: #f5f5f5;
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}
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.page {
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width: 210mm;
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height: 297mm;
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max-width: none;
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margin: 20px auto;
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background: #fff;
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padding: 33px;
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}
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h1 {
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text-align: center;
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font-size: 22px;
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font-weight: normal;
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line-height: 33px;
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}
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/* --- Date row --- */
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.date-row {
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display: flex;
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flex-wrap: wrap;
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justify-content: space-between;
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gap: 6px 12px;
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padding: 16px 0;
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}
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.date-group {
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display: flex;
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flex-wrap: wrap;
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align-items: center;
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min-width: 0;
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max-width: 100%;
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}
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/* --- Underline input --- */
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input[type="text"] {
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border: none;
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border-bottom: 1px solid #d1d5dc;
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outline: none;
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font-size: 14px;
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padding: 2px 4px;
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font-family: inherit;
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background: transparent;
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color: #364153;
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text-align: center;
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height: 27.75px;
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field-sizing: content;
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width: auto;
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min-width: var(--field-min-width, 40px);
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max-width: 100%;
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flex: 0 1 auto;
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}
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input.w-xs { --field-min-width: 44px; }
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input.w-sm { --field-min-width: 40px; }
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input.w-md { --field-min-width: 60px; }
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input.w-lg { --field-min-width: 120px; }
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input.w-xl { --field-min-width: 160px; }
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input.w-xxl { --field-min-width: 200px; }
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/* --- Checkbox and radio --- */
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input[type="checkbox"],
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input[type="radio"] {
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-webkit-appearance: none;
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-moz-appearance: none;
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appearance: none;
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display: inline-block;
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width: 15px;
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height: 15px;
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border: 1px solid #6a7282;
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border-radius: 3px;
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background: #fff;
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flex-shrink: 0;
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vertical-align: middle;
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position: relative;
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top: -1px;
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margin: 0;
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cursor: pointer;
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}
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input[type="checkbox"]:checked,
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input[type="radio"]:checked {
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background: #364153;
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border-color: #364153;
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}
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input[type="checkbox"]:checked::after,
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input[type="radio"]:checked::after {
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content: "✓";
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color: #fff;
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font-size: 11px;
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position: absolute;
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inset: 0;
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display: flex;
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align-items: center;
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justify-content: center;
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line-height: 1;
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}
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input[type="checkbox"]:focus-visible,
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input[type="radio"]:focus-visible {
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outline: 2px solid #5b8def;
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outline-offset: 1px;
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}
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.opt {
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display: inline-flex;
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align-items: center;
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gap: 6px;
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white-space: nowrap;
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margin-right: 12px;
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}
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/* --- Info box --- */
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.info-box {
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border: 1px solid #d1d5dc;
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border-radius: 10px;
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padding: 16px;
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margin: 16px 0;
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font-size: 13.5px;
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line-height: 22px;
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}
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.info-box p { margin-bottom: 6px; }
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.sign-row {
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display: flex;
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align-items: center;
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flex-wrap: wrap;
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gap: 8px;
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}
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/* --- Category table --- */
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.cat-table {
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width: 100%;
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border-collapse: collapse;
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border: 1px solid #d1d5dc;
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margin-top: 16px;
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}
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.cat-table td {
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border: 1px solid #d1d5dc;
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padding: 0;
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vertical-align: top;
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text-align: left;
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}
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.cat-label {
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width: 86px;
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text-align: center;
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vertical-align: middle !important;
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font-weight: normal;
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font-size: 15px;
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line-height: 21px;
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padding: 8px !important;
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background: #fff;
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}
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/* --- Line (row inside content cell) --- */
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.line {
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display: flex;
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flex-wrap: wrap;
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align-items: center;
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gap: 16px;
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padding: 10px 16px;
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border-bottom: 1px solid rgba(209,213,220,0.7);
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}
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.line:last-child { border-bottom: none; }
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.field-group {
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display: inline-flex;
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flex-wrap: wrap;
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align-items: center;
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gap: 2px;
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min-width: 0;
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max-width: 100%;
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}
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/* --- Checkbox/option group --- */
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.check-group {
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display: flex;
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flex-wrap: wrap;
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gap: 8px 20px;
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padding: 10px 16px;
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}
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/* --- Sub-labels --- */
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.sub-label { color: #6a7282; white-space: nowrap; }
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/* --- Question block --- */
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.q-block {
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padding: 10px 16px;
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border-bottom: 1px solid rgba(209,213,220,0.7);
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}
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.q-block:last-child { border-bottom: none; }
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.q-title { margin-bottom: 8px; }
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.q-options {
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display: flex;
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flex-wrap: wrap;
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gap: 8px;
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padding-left: 16px;
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}
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/* --- Result rows --- */
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.result-row {
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display: flex;
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padding: 10px 16px;
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border-bottom: 1px solid rgba(209,213,220,0.7);
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}
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.result-row:last-child { border-bottom: none; }
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.result-label {
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width: 140px;
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min-width: 140px;
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padding-top: 2px;
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}
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.result-options {
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flex: 1;
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display: flex;
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flex-wrap: wrap;
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gap: 6px 16px;
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}
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/* --- Lab fields --- */
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.lab-section {
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padding: 10px 16px;
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border-bottom: 1px solid rgba(209,213,220,0.7);
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}
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.lab-section:last-child { border-bottom: none; }
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.lab-title { margin-bottom: 6px; }
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.lab-row {
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display: flex;
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flex-wrap: wrap;
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gap: 8px 24px;
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padding: 4px 0;
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}
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.lab-item {
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display: inline-flex;
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flex-wrap: wrap;
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align-items: center;
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gap: 2px;
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min-width: 0;
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max-width: 100%;
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}
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.lab-note {
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font-size: 13px;
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color: #6a7282;
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padding: 4px 0;
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}
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/* --- Institution --- */
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.inst-row { display: flex; }
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.inst-cell {
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flex: 1;
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padding: 16px;
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border-right: 1px solid rgba(209,213,220,0.7);
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}
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.inst-cell:last-child { border-right: none; }
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.inst-cell .cell-title {
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font-size: 13.5px;
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color: #6a7282;
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padding-bottom: 4px;
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}
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.inst-cell .cell-value {
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font-size: 13.5px;
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line-height: 22px;
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}
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.institution-inputs {
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display: flex;
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flex-wrap: wrap;
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align-items: center;
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gap: 2px;
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}
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.institution-inputs input[type="text"] { border-bottom: none; }
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.institution-contact-inputs {
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flex-direction: column;
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flex-wrap: nowrap;
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align-items: flex-start;
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gap: 4px;
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}
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.institution-contact-inputs input[type="text"] { text-align: left; }
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.institution-phone-row {
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display: flex;
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flex-wrap: wrap;
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align-items: center;
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gap: 2px;
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max-width: 100%;
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}
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#field-institutionPhoneAreaCode { min-width: 0; }
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.sign-line {
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border-bottom: 1px solid #d1d5dc;
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height: 30px;
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margin-top: 10px;
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}
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/* --- Footer --- */
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.footer-notes {
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margin-top: 16px;
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font-size: 12.5px;
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line-height: 20px;
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color: #6a7282;
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}
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.footer-notes p { margin-bottom: 4px; }
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/* --- A4 form-page density (desktop only) --- */
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@media (min-width: 801px) {
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.form-page {
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padding: 8mm;
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font-size: 10px;
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line-height: 1.25;
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display: flex;
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flex-direction: column;
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}
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.form-page h1 {
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font-size: 17px;
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line-height: 22px;
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}
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.form-page .date-row { padding: 6px 0; }
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.form-page input[type="text"] {
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height: 18px;
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padding: 1px 2px;
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font-size: 10px;
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}
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.form-page input[type="checkbox"],
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.form-page input[type="radio"] {
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width: 10px;
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height: 10px;
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border-radius: 2px;
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}
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.form-page input[type="checkbox"]:checked::after,
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.form-page input[type="radio"]:checked::after {
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font-size: 8px;
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}
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.form-page .opt {
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gap: 3px;
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margin-right: 6px;
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}
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.form-page .info-box {
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padding: 7px;
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margin: 7px 0;
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border-radius: 6px;
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font-size: 9.5px;
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line-height: 13px;
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}
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.form-page .info-box p { margin-bottom: 2px; }
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.form-page .sign-row { gap: 4px; }
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.form-page .cat-table {
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margin-top: 6px;
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flex: 1;
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}
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.form-page .cat-label {
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width: 58px;
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padding: 4px !important;
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font-size: 10px;
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line-height: 13px;
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}
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.form-page .line {
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gap: 6px;
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padding: 4px 7px;
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}
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.form-page .check-group {
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gap: 4px 8px;
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padding: 4px 7px;
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}
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.form-page .q-block { padding: 4px 7px; }
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.form-page .q-title { margin-bottom: 3px; }
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.form-page .q-options {
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gap: 3px;
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padding-left: 6px;
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}
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.form-page .result-row { padding: 4px 7px; }
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.form-page .result-label {
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width: 90px;
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min-width: 90px;
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padding-top: 1px;
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}
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.form-page .result-options { gap: 3px 8px; }
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.form-page .lab-section { padding: 4px 7px; }
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.form-page .lab-title { margin-bottom: 3px; }
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.form-page .lab-row {
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gap: 4px 12px;
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padding: 2px 0;
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}
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.form-page .lab-note {
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padding: 2px 0;
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font-size: 9px;
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}
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.form-page .inst-cell { padding: 7px; }
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.form-page .inst-cell .cell-title {
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padding-bottom: 2px;
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font-size: 9px;
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}
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.form-page .inst-cell .cell-value {
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font-size: 9px;
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line-height: 12px;
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}
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.form-page .sign-line {
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height: 18px;
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margin-top: 4px;
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}
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.form-page .footer-notes {
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margin-top: 6px;
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font-size: 8.5px;
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line-height: 11px;
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}
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.form-page .footer-notes p { margin-bottom: 2px; }
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.form-page input.w-xs { --field-min-width: 28px; }
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.form-page input.w-sm { --field-min-width: 26px; }
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.form-page input.w-md { --field-min-width: 40px; }
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.form-page input.w-lg { --field-min-width: 70px; }
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.form-page input.w-xl { --field-min-width: 100px; }
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.form-page input.w-xxl { --field-min-width: 120px; }
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} /* end @media min-width:801px */
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.continuation-page .cat-table { margin-top: 0; }
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/* --- Page 3: 衛教建議 --- */
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.page2-wrapper {
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width: 210mm;
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height: 297mm;
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max-width: none;
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margin: 20px auto;
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background: #fff;
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padding: 33px;
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display: flex;
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flex-direction: column;
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overflow: hidden;
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}
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.edu-box {
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border: 1px solid #d1d5dc;
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border-radius: 8px;
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display: flex;
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flex-direction: column;
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flex: 1;
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min-height: 0;
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}
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.edu-title {
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text-align: center;
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font-size: 16px;
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font-weight: normal;
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line-height: 30px;
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padding: 16px;
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border-bottom: 1px solid #d1d5dc;
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}
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.edu-content {
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flex: 1;
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padding: 16px;
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}
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/* --- Address --- */
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.addr-wrap {
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display: flex;
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flex-wrap: wrap;
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align-items: center;
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gap: 2px;
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}
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/* --- Exam grid (胸/心/呼吸/腹/四肢 2-col) --- */
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.exam-grid {
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display: grid;
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grid-template-columns: 1fr 1fr;
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border-bottom: 1px solid rgba(209,213,220,0.7);
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}
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.exam-grid:last-child { border-bottom: none; }
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.exam-grid .eg-cell {
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padding: 4px 7px;
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display: flex;
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flex-wrap: wrap;
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align-items: center;
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gap: 6px;
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}
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.exam-grid .eg-cell:first-child {
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border-right: 1px solid rgba(209,213,220,0.7);
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}
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/* ===== Normalize form-page field min-widths (handled inside @media min-width:801px above) ===== */
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/* ===== RWD: mobile ===== */
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@media (max-width: 800px) {
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.page, .page2-wrapper {
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width: 100%;
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height: auto;
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min-height: auto;
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margin: 0;
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padding: 16px;
|
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font-size: 13px;
|
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line-height: 1.4;
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}
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.page + .page, .page2-wrapper { margin-top: 12px; }
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h1 { font-size: 18px; line-height: 26px; }
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|
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/* inputs */
|
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input[type="text"] {
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height: 24px;
|
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font-size: 13px;
|
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min-width: 0;
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--field-min-width: 32px;
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}
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input.w-xs { --field-min-width: 32px; }
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input.w-sm { --field-min-width: 28px; }
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input.w-md { --field-min-width: 44px; }
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input.w-lg { --field-min-width: 80px; }
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input.w-xl { --field-min-width: 100px; }
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input.w-xxl { --field-min-width: 130px; }
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/* clamp inline --field-min-width so nothing overflows */
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input[type="text"] { max-width: 100%; }
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|
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/* checkbox/radio */
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input[type="checkbox"],
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input[type="radio"] { width: 14px; height: 14px; }
|
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input[type="checkbox"]:checked::after,
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input[type="radio"]:checked::after { font-size: 10px; }
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.opt { gap: 4px; margin-right: 8px; }
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|
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/* info box */
|
|
.info-box { padding: 10px; margin: 10px 0; font-size: 12px; line-height: 17px; border-radius: 8px; }
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|
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/* table */
|
|
.cat-table { margin-top: 8px; }
|
|
.cat-label { width: 52px; padding: 4px !important; font-size: 12px; line-height: 16px; }
|
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.line { gap: 8px; padding: 6px 10px; }
|
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.check-group { gap: 6px 12px; padding: 6px 10px; }
|
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.field-group { gap: 2px; }
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|
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/* questions */
|
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.q-block { padding: 6px 10px; }
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.q-options { gap: 6px; padding-left: 8px; }
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|
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/* results */
|
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.result-row { padding: 6px 10px; flex-wrap: wrap; }
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.result-label { width: auto; min-width: auto; margin-right: 8px; font-weight: 500; }
|
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.result-options { gap: 4px 10px; }
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|
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/* lab */
|
|
.lab-section { padding: 6px 10px; }
|
|
.lab-row { gap: 4px 12px; }
|
|
.lab-item { white-space: normal; }
|
|
.lab-note { font-size: 11px; }
|
|
|
|
/* institution */
|
|
.inst-row { flex-direction: column; }
|
|
.inst-cell { border-right: none !important; border-bottom: 1px solid rgba(209,213,220,0.7); padding: 10px; }
|
|
.inst-cell:last-child { border-bottom: none; }
|
|
|
|
/* footer */
|
|
.footer-notes { font-size: 11px; line-height: 16px; }
|
|
|
|
/* exam grid → stack on mobile */
|
|
.exam-grid { grid-template-columns: 1fr; }
|
|
.exam-grid .eg-cell:first-child { border-right: none; border-bottom: 1px solid rgba(209,213,220,0.7); }
|
|
|
|
/* page 3 edu */
|
|
.edu-title { font-size: 15px; padding: 12px; }
|
|
.edu-content { padding: 12px; }
|
|
}
|
|
|
|
/* ===== RWD: very small screens ===== */
|
|
@media (max-width: 480px) {
|
|
.page, .page2-wrapper { padding: 10px; }
|
|
h1 { font-size: 16px; }
|
|
.cat-label { width: 40px; font-size: 10px; }
|
|
.date-row { flex-direction: column; gap: 4px; }
|
|
input[type="text"] { font-size: 12px; height: 22px; }
|
|
.opt { margin-right: 4px; font-size: 12px; }
|
|
.result-row { flex-direction: column; }
|
|
.result-label { width: 100%; min-width: 100%; margin-bottom: 4px; }
|
|
}
|
|
|
|
@page {
|
|
size: A4 portrait;
|
|
margin: 0;
|
|
}
|
|
|
|
@media print {
|
|
body { background: #fff; }
|
|
.page, .page2-wrapper {
|
|
width: 210mm;
|
|
height: 297mm;
|
|
margin: 0;
|
|
padding: 8mm;
|
|
box-shadow: none;
|
|
border: none;
|
|
border-radius: 0;
|
|
}
|
|
.page, .page2-wrapper {
|
|
break-after: page;
|
|
page-break-after: always;
|
|
}
|
|
.page2-wrapper {
|
|
break-after: auto;
|
|
page-break-after: auto;
|
|
}
|
|
}
|
|
</style>
|
|
<meta name="adult-health-check-stored-only" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_consent" data-reason="同意紀錄僅作內部資料庫留存，不直接填入畫面簽名格">
|
|
<meta name="adult-health-check-stored-only" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f11_prev_hep_test" data-reason="依現行規格僅保存答案，不建立HTML/PDF輸出對應">
|
|
<meta name="adult-health-check-stored-only" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_cancer_type" data-reason="依現行規格僅保存家族癌症類別，不套印至HTML畫面">
|
|
</head>
|
|
<body>
|
|
|
|
<div class="page form-page page-one">
|
|
<h1>健康署成人預防保健服務檢查紀錄結果表單</h1>
|
|
|
|
<!-- Date row -->
|
|
<div class="date-row">
|
|
<div class="date-group">
|
|
<span>第一階段日期：民國</span>
|
|
<input type="text" class="w-xs" data-source="case-record" data-output-field="stage1_date"> <span>年</span>
|
|
<input type="text" class="w-sm" data-source="case-record" data-output-field="stage1_date"> <span>月</span>
|
|
<input type="text" class="w-sm" data-source="case-record" data-output-field="stage1_date"> <span>日</span>
|
|
</div>
|
|
<div class="date-group">
|
|
<span>第二階段日期：民國</span>
|
|
<input type="text" class="w-xs" data-source="case-record" data-output-field="stage2_date"> <span>年</span>
|
|
<input type="text" class="w-sm" data-source="case-record" data-output-field="stage2_date"> <span>月</span>
|
|
<input type="text" class="w-sm" data-source="case-record" data-output-field="stage2_date"> <span>日</span>
|
|
</div>
|
|
</div>
|
|
|
|
<!-- Info / consent box -->
|
|
<div class="info-box">
|
|
<p>◎ 成人預防保健服務補助時程為三十歲以上未滿四十歲者，每五年補助一次；四十歲以上未滿六十五歲者，每三年補助一次；三十五歲以上小兒麻痺患者、五十五歲以上原住民或六十五歲以上者，每年補助一次。</p>
|
|
<div class="sign-row" style="margin-bottom:6px;">
|
|
<span>◎ 本人同意接受成人預防保健服務。請簽名或蓋章（手印）：</span>
|
|
<span>（第一階）</span><input type="text" class="w-lg" data-source="signature-evidence" data-output-field="stage1_consent_signature">
|
|
<span>（第二階）</span><input type="text" class="w-lg" data-source="signature-evidence" data-output-field="stage2_consent_signature">
|
|
</div>
|
|
<p>◎ 成人預防保健服務 B、C 型肝炎檢查補助時程經機構查詢符合檢查條件者，終身一次。本人同意接受檢查，請簽名或蓋章（手印）：</p>
|
|
<div style="padding-left:16px;"><input type="text" class="w-xl" data-source="signature-evidence" data-output-field="hepatitis_consent_signature"></div>
|
|
<p style="text-align:center; margin-top:8px; color:#6a7282;">（相關資料將作為衛生單位政策評估及查詢或個案追蹤健康管理使用）</p>
|
|
</div>
|
|
|
|
<!-- Main table -->
|
|
<table class="cat-table">
|
|
|
|
<!-- ===== 基本資料 ===== -->
|
|
<tr>
|
|
<td class="cat-label" rowspan="4">基本資料</td>
|
|
<td>
|
|
<div class="line">
|
|
<span class="field-group"><span>身分證統一編號</span> <input type="text" style="--field-min-width:150px;" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f01_idno"></span>
|
|
<span class="field-group"><span>姓名</span> <input type="text" class="w-lg" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f59_name"></span>
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>性別</span>
|
|
<span class="opt"><input type="radio" name="f02_gender" value="男" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f02_gender" data-match-value="1"> 男</span>
|
|
<span class="opt"><input type="radio" name="f02_gender" value="女" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f02_gender" data-match-value="2"> 女</span>
|
|
</span>
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>原住民</span>
|
|
<span class="opt"><input type="radio" name="nr_indigenous" value="是" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_indigenous" data-match-value="Y"> 是</span>
|
|
<span class="opt"><input type="radio" name="nr_indigenous" value="否" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_indigenous" data-match-value="N"> 否</span>
|
|
</span>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
<tr>
|
|
<td>
|
|
<div class="line">
|
|
<span class="field-group">
|
|
<span>生日 民國前/後</span>
|
|
<input type="text" class="w-xs" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f03_birth"> <span>年</span>
|
|
<input type="text" class="w-sm" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f03_birth"> <span>月</span>
|
|
<input type="text" class="w-sm" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f03_birth"> <span>日（</span>
|
|
<input type="text" class="w-sm" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_age"> <span>足歲）</span>
|
|
</span>
|
|
<span class="field-group">
|
|
<span>電話（</span><input type="text" style="--field-min-width:40px;" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f04_phone"><span>）</span><input type="text" style="--field-min-width:140px;" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f04_phone">
|
|
</span>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
<tr>
|
|
<td>
|
|
<div class="line">
|
|
<span class="sub-label">現地址</span>
|
|
<div class="addr-wrap">
|
|
<input type="text" style="--field-min-width:70px;" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_county"> <span>縣（市）</span>
|
|
<input type="text" style="--field-min-width:80px;" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_district"> <span>鄉鎮市區</span>
|
|
<input type="text" style="--field-min-width:70px;" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_detail"> <span>村里</span>
|
|
<input type="text" class="w-sm" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_detail"> <span>鄰</span>
|
|
<input type="text" style="--field-min-width:90px;" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_detail"> <span>路（街）</span>
|
|
<input type="text" class="w-sm" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_detail"> <span>段</span>
|
|
<input type="text" class="w-sm" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_detail"> <span>巷</span>
|
|
<input type="text" class="w-sm" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_detail"> <span>弄</span>
|
|
<input type="text" class="w-sm" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_detail"> <span>號</span>
|
|
<input type="text" class="w-sm" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_addr_detail"> <span>樓</span>
|
|
</div>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
<tr>
|
|
<td>
|
|
<div class="line" style="border-bottom:none;">
|
|
<span class="field-group">
|
|
<span class="sub-label">戶籍地</span> <input type="text" class="w-lg" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f05_household_city"> <span>縣（市）</span>
|
|
</span>
|
|
<span class="field-group" style="gap:12px;">
|
|
<span>教育程度</span>
|
|
<span class="opt"><input type="radio" name="nr_education" value="無" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_education" data-match-value="無"> 無</span>
|
|
<span class="opt"><input type="radio" name="nr_education" value="小學" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_education" data-match-value="小學"> 小學</span>
|
|
<span class="opt"><input type="radio" name="nr_education" value="國初中" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_education" data-match-value="國（初）中"> 國（初）中</span>
|
|
<span class="opt"><input type="radio" name="nr_education" value="高中職" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_education" data-match-value="高中（職）"> 高中（職）</span>
|
|
<span class="opt"><input type="radio" name="nr_education" value="專科大學" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_education" data-match-value="專科、大學"> 專科、大學</span>
|
|
<span class="opt"><input type="radio" name="nr_education" value="研究所以上" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_education" data-match-value="研究所以上"> 研究所以上</span>
|
|
</span>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
<!-- ===== 疾病史 ===== -->
|
|
<tr>
|
|
<td class="cat-label">疾病史</td>
|
|
<td>
|
|
<div class="check-group">
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="高血壓" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="htn"> 高血壓</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="糖尿病" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="dm"> 糖尿病</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="高血脂症" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="lipid"> 高血脂症</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="心臟病" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="heart"> 心臟病</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="腦中風" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="stroke"> 腦中風</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="腎臟病" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="renal"> 腎臟病</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="B型肝炎" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="hbv"> B 型肝炎</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="C型肝炎" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="hcv"> C 型肝炎</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="精神疾病" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="mental"> 精神疾病</span>
|
|
<span class="field-group">
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="其他" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="other"> 其他</span>
|
|
<input type="text" style="--field-min-width:140px;" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_other">
|
|
</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="小兒麻痺" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="polio"> 小兒麻痺</span>
|
|
<span class="opt"><input type="checkbox" name="nr_disease_history" value="以上均無" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_disease_history" data-match-value="none"> 以上均無</span>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
<!-- ===== 長期服藥 ===== -->
|
|
<tr>
|
|
<td class="cat-label">長期服藥</td>
|
|
<td>
|
|
<div class="line" style="border-bottom:none;">
|
|
<span class="opt"><input type="radio" name="nr_longterm_med" value="無" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_longterm_med" data-match-value="no"> 無</span>
|
|
<span class="field-group">
|
|
<span class="opt"><input type="radio" name="nr_longterm_med" value="有" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_longterm_med" data-match-value="yes"> 有</span>
|
|
<span>，病因</span> <input type="text" class="w-xxl" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_longterm_med_reason">
|
|
</span>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
<!-- ===== 家族史 ===== -->
|
|
<tr>
|
|
<td class="cat-label">家族史</td>
|
|
<td>
|
|
<div class="check-group">
|
|
<span class="opt"><input type="checkbox" name="nr_family_history" value="高血壓" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_history" data-match-value="htn"> 高血壓</span>
|
|
<span class="opt"><input type="checkbox" name="nr_family_history" value="糖尿病" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_history" data-match-value="dm"> 糖尿病</span>
|
|
<span class="opt"><input type="checkbox" name="nr_family_history" value="血脂異常" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_history" data-match-value="lipid"> 血脂異常</span>
|
|
<span class="opt"><input type="checkbox" name="nr_family_history" value="心臟病" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_history" data-match-value="heart"> 心臟病</span>
|
|
<span class="opt"><input type="checkbox" name="nr_family_history" value="腦中風" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_history" data-match-value="stroke"> 腦中風</span>
|
|
<span class="opt"><input type="checkbox" name="nr_family_history" value="精神疾病" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_history" data-match-value="mental"> 精神疾病</span>
|
|
<span class="field-group">
|
|
<span class="opt"><input type="checkbox" name="nr_family_history" value="癌症" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_history" data-match-value="cancer"> 癌症</span>
|
|
<input type="text" style="--field-min-width:80px;" data-source="unmapped" data-output-field="family_cancer_type">
|
|
</span>
|
|
<span class="field-group">
|
|
<span class="opt"><input type="checkbox" name="nr_family_history" value="其他" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_history" data-match-value="other"> 其他：</span>
|
|
<input type="text" style="--field-min-width:160px;" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_other">
|
|
</span>
|
|
<span class="opt"><input type="checkbox" name="nr_family_history" value="以上均無" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_family_history" data-match-value="none"> 以上均無</span>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
<!-- ===== 健康行為 ===== -->
|
|
<tr>
|
|
<td class="cat-label">健康行為</td>
|
|
<td>
|
|
<div class="q-block">
|
|
<div class="q-title">一、最近半年來，您吸菸的情形是？</div>
|
|
<div class="q-options">
|
|
<span class="opt"><input type="radio" name="f18_smoking" value="不吸菸" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f18_smoking" data-match-value="1"> 不吸菸</span>
|
|
<span class="opt"><input type="radio" name="f18_smoking" value="應酬" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f18_smoking" data-match-value="2"> 朋友敬菸或應酬才吸菸</span>
|
|
<span class="opt"><input type="radio" name="f18_smoking" value="一包以下" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f18_smoking" data-match-value="3"> 平均一天約吸一包菸（含以下）</span>
|
|
<span class="opt"><input type="radio" name="f18_smoking" value="一包以上" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f18_smoking" data-match-value="4"> 平均一天約吸一包菸以上</span>
|
|
</div>
|
|
</div>
|
|
<div class="q-block">
|
|
<div class="q-title">二、最近半年來，您喝酒的情形是？</div>
|
|
<div class="q-options">
|
|
<span class="opt"><input type="radio" name="f19_drinking" value="不喝酒" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f19_drinking" data-match-value="1"> 不喝酒</span>
|
|
<span class="opt"><input type="radio" name="f19_drinking" value="偶爾" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f19_drinking" data-match-value="2"> 偶爾喝酒或應酬才喝</span>
|
|
<span class="opt"><input type="radio" name="f19_drinking" value="經常" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f19_drinking" data-match-value="3"> 經常喝酒</span>
|
|
</div>
|
|
</div>
|
|
<div class="q-block">
|
|
<div class="q-title">三、最近半年來，您嚼檳榔的情形是？</div>
|
|
<div class="q-options">
|
|
<span class="opt"><input type="radio" name="f20_betelnut" value="不嚼" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f20_betelnut" data-match-value="1"> 不嚼檳榔</span>
|
|
<span class="opt"><input type="radio" name="f20_betelnut" value="偶爾" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f20_betelnut" data-match-value="2"> 偶爾會嚼或應酬才嚼</span>
|
|
<span class="opt"><input type="radio" name="f20_betelnut" value="經常" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f20_betelnut" data-match-value="3"> 經常嚼或習慣嚼</span>
|
|
</div>
|
|
</div>
|
|
<div class="q-block">
|
|
<div class="q-title">四、最近二週，您是否有運動（每週達 150 分鐘以上）？</div>
|
|
<div class="q-options">
|
|
<span class="opt"><input type="radio" name="f21_exercise" value="沒有" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f21_exercise" data-match-value="1"> 沒有</span>
|
|
<span class="opt"><input type="radio" name="f21_exercise" value="未達150" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f21_exercise" data-match-value="2"> 有，但未達每週 150 分鐘（2.5 小時）</span>
|
|
<span class="opt"><input type="radio" name="f21_exercise" value="達150" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="f21_exercise" data-match-value="3"> 有，且每週達 150 分鐘以上（2.5 小時）</span>
|
|
</div>
|
|
</div>
|
|
<div class="q-block" style="border-bottom:none;">
|
|
<div class="q-title">五、您是否出現咳嗽超過二週的情形？</div>
|
|
<div class="q-options">
|
|
<span class="opt"><input type="radio" name="nr_cough" value="沒有" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_cough" data-match-value="1"> 沒有</span>
|
|
<span class="opt"><input type="radio" name="nr_cough" value="有" data-form-code="ADULT_HEALTH_CHECK_PERSONAL" data-answer-path="nr_cough" data-match-value="2"> 有</span>
|
|
</div>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
<!-- ===== 身體檢查 ===== -->
|
|
<tr>
|
|
<td class="cat-label">身體檢查</td>
|
|
<td>
|
|
<div class="line">
|
|
<span class="field-group"><span>身高：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="f_body_measures.height"> <span>公分</span></span>
|
|
<span class="field-group"><span>體重：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="f_body_measures.weight"> <span>公斤</span></span>
|
|
<span class="field-group"><span>脈搏：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="f_vitals.pulse"> <span>次/分</span></span>
|
|
<span class="field-group"><span>血壓：</span> <input type="text" style="--field-min-width:50px;" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="f_vitals.sbp"> <span>／</span> <input type="text" style="--field-min-width:50px;" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="f_vitals.dbp"> <span>mmHg</span></span>
|
|
<span class="field-group"><span>腰圍：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="f_body_measures.waist"> <span>公分</span></span>
|
|
</div>
|
|
<div class="line">
|
|
<span class="field-group"><span>身體質量指數（BMI）：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="f29_bmi"> <span style="font-size:13px; color:#6a7282;">【理想值：18.5≦BMI＜24】</span></span>
|
|
<span style="font-size:13px; color:#6a7282;">◎計算方式：體重（公斤）／身高（公尺）²</span>
|
|
</div>
|
|
<div class="line">
|
|
<span>眼睛</span>
|
|
<span class="field-group"><span>右眼裸眼視力：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_vision.right_naked"></span>
|
|
<span class="field-group"><span>左眼裸眼視力：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_vision.left_naked"></span>
|
|
<span class="field-group"><span>右眼矯正視力：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_vision.right_corrected"></span>
|
|
<span class="field-group"><span>左眼矯正視力：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_vision.left_corrected"></span>
|
|
</div>
|
|
<div class="line">
|
|
<span>耳鼻喉及口腔</span>
|
|
<span class="opt"><input type="checkbox" name="nr_ent" value="無明顯異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_ent" data-match-value="normal"> 無明顯異常</span>
|
|
<span class="opt"><input type="checkbox" name="nr_ent" value="異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_ent" data-match-value="abnormal"> 異常：</span>
|
|
<span class="opt"><input type="checkbox" name="nr_ent_detail" value="助聽器" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_ent_detail" data-match-value="hearing_aid"> 助聽器</span>
|
|
<span class="opt"><input type="checkbox" name="nr_ent_detail" value="齲齒" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_ent_detail" data-match-value="caries"> 齲齒</span>
|
|
<span class="opt"><input type="checkbox" name="nr_ent_detail" value="牙結石或牙周病" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_ent_detail" data-match-value="periodontal"> 牙結石或牙周病</span>
|
|
<span class="field-group">
|
|
<span class="opt"><input type="checkbox" name="nr_ent_detail" value="其他" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_ent_detail" data-match-value="other"> 其他</span>
|
|
<input type="text" style="--field-min-width:100px;" data-source="unmapped" data-output-field="ent_other_note">
|
|
</span>
|
|
</div>
|
|
<div class="line">
|
|
<span>頸部</span>
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>淋巴腺腫大：</span>
|
|
<span class="opt"><input type="radio" name="nr_neck.lymph.result" value="有" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_neck.lymph.result" data-match-value="yes"> 有</span>
|
|
<span class="opt"><input type="radio" name="nr_neck.lymph.result" value="無" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_neck.lymph.result" data-match-value="no"> 無</span>
|
|
</span>
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>甲狀腺腫大：</span>
|
|
<span class="opt"><input type="radio" name="nr_neck.thyroid.result" value="有" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_neck.thyroid.result" data-match-value="yes"> 有</span>
|
|
<span class="opt"><input type="radio" name="nr_neck.thyroid.result" value="無" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_neck.thyroid.result" data-match-value="no"> 無</span>
|
|
</span>
|
|
</div>
|
|
<div class="line">
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>胸 部：</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.chest.status" value="無明顯異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.chest.status" data-match-value="normal"> 無明顯異常</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.chest.status" value="異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.chest.status" data-match-value="abnormal"> 異常：</span>
|
|
<input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.chest.note">
|
|
</span>
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>心臟聽診：</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.heart.status" value="無明顯異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.heart.status" data-match-value="normal"> 無明顯異常</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.heart.status" value="異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.heart.status" data-match-value="abnormal"> 異常：</span>
|
|
<input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.heart.note">
|
|
</span>
|
|
</div>
|
|
<div class="line">
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>呼吸聽診：</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.lung.status" value="無明顯異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.lung.status" data-match-value="normal"> 無明顯異常</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.lung.status" value="異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.lung.status" data-match-value="abnormal"> 異常：</span>
|
|
<input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.lung.note">
|
|
</span>
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>腹 部：</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.abdomen.status" value="無明顯異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.abdomen.status" data-match-value="normal"> 無明顯異常</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.abdomen.status" value="異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.abdomen.status" data-match-value="abnormal"> 異常：</span>
|
|
<input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.abdomen.note">
|
|
</span>
|
|
</div>
|
|
<div class="line" style="border-bottom:none;">
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>四 肢：</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.limbs.status" value="無明顯異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.limbs.status" data-match-value="normal"> 無明顯異常</span>
|
|
<span class="opt"><input type="radio" name="nr_exam_matrix.limbs.status" value="異常" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.limbs.status" data-match-value="abnormal"> 異常：</span>
|
|
<input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_exam_matrix.limbs.note">
|
|
</span>
|
|
<span class="field-group"><span>其他異常：</span> <input type="text" style="--field-min-width:160px;" data-form-code="ADULT_HEALTH_CHECK_PHYSICAL" data-answer-path="nr_other_abnormal"></span>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
</table>
|
|
</div>
|
|
|
|
<!-- Page 2: 檢驗與結果 -->
|
|
<div class="page form-page page-two continuation-page">
|
|
<table class="cat-table continuation-table">
|
|
<!-- ===== 檢驗室檢查 ===== -->
|
|
<tr>
|
|
<td class="cat-label">檢驗室<br>檢查</td>
|
|
<td>
|
|
<!-- 尿液 -->
|
|
<div class="lab-section">
|
|
<div class="lab-title">尿液檢查</div>
|
|
<div class="lab-row" style="gap:8px; padding-left:8px;">
|
|
<span>蛋白質：定性</span>
|
|
<span class="opt"><input type="radio" name="nr_urine_qual" value="－" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-mode-path="nr_urine_mode" data-answer-path="nr_urine_qual" data-match-value="0000">：－</span>
|
|
<span class="opt"><input type="radio" name="nr_urine_qual" value="+/－" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-mode-path="nr_urine_mode" data-answer-path="nr_urine_qual" data-match-value="1100">：+/－</span>
|
|
<span class="opt"><input type="radio" name="nr_urine_qual" value="+" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-mode-path="nr_urine_mode" data-answer-path="nr_urine_qual" data-match-value="1111">：+</span>
|
|
<span class="opt"><input type="radio" name="nr_urine_qual" value="++" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-mode-path="nr_urine_mode" data-answer-path="nr_urine_qual" data-match-value="2222">：++</span>
|
|
<span class="opt"><input type="radio" name="nr_urine_qual" value="+++" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-mode-path="nr_urine_mode" data-answer-path="nr_urine_qual" data-match-value="3333">：+++</span>
|
|
<span class="opt"><input type="radio" name="nr_urine_qual" value="++++" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-mode-path="nr_urine_mode" data-answer-path="nr_urine_qual" data-match-value="4444">：++++</span>
|
|
<span class="field-group">
|
|
<span>或定量：</span> <input type="text" style="--field-min-width:70px;" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-mode-path="nr_urine_mode" data-answer-path="nr_urine_quant"> <span>mg/dl（參考值：</span><input type="text" style="--field-min-width:70px;" data-source="unmapped" data-output-field="urine_protein_quant_ref"><span>）</span>
|
|
</span>
|
|
</div>
|
|
<div class="lab-note" style="padding-left:8px;">【定性或定量可擇一填寫】</div>
|
|
</div>
|
|
<!-- 生化 -->
|
|
<div class="lab-section">
|
|
<div class="lab-title">生化檢查</div>
|
|
<div class="lab-row" style="padding-left:8px;">
|
|
<span class="lab-item"><span>飯前血糖：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f31_glucose.value"> <span>mg/dl（參考值：</span><input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f31_glucose.ref"><span>）</span></span>
|
|
<span class="lab-item"><span>總膽固醇：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f32_cholesterol.value"> <span>mg/dl（參考值：</span><input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f32_cholesterol.ref"><span>）</span></span>
|
|
</div>
|
|
<div class="lab-row" style="padding-left:8px;">
|
|
<span class="lab-item"><span>三酸甘油脂：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f33_triglyceride.value"> <span>mg/dl（參考值：</span><input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f33_triglyceride.ref"><span>）</span></span>
|
|
<span class="lab-item"><span>高密度脂蛋白膽固醇：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f35_hdl.value"> <span>mg/dl（參考值：</span><input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f35_hdl.ref"><span>）</span></span>
|
|
</div>
|
|
<div class="lab-row" style="padding-left:8px;">
|
|
<span class="lab-item"><span>低密度脂蛋白膽固醇計算：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f34_ldl.value"> <span>mg/dl（參考值：</span><input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_lipid.f34_ldl.ref"><span>）</span> <span style="font-size:13px; color:#6a7282;">（僅適用三酸甘油脂≦400 mg/dl）</span></span>
|
|
<span class="lab-item"><span>AST（GOT）：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_liver.f36_got.value"> <span>IU/L（參考值：</span><input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_liver.f36_got.ref"><span>）</span></span>
|
|
</div>
|
|
<div class="lab-row" style="padding-left:8px;">
|
|
<span class="lab-item"><span>ALT（GPT）：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_liver.f37_gpt.value"> <span>IU/L（參考值：</span><input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_liver.f37_gpt.ref"><span>）</span></span>
|
|
<span class="lab-item"><span>肌酸酐：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_liver.f38_creatinine.value"> <span>mg/dl（參考值：</span><input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_biochem_liver.f38_creatinine.ref"><span>）</span></span>
|
|
<span class="lab-item"><span>尿酸：</span> <input type="text" class="w-md" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f62_uric_acid"> <span>mg/dl</span></span>
|
|
</div>
|
|
<div class="lab-row" style="padding-left:8px;">
|
|
<span class="lab-item"><span>腎絲球過濾率（eGFR）：</span> <input type="text" style="--field-min-width:90px;" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f39_egfr"> <span>ml/min/1.73 m²</span></span>
|
|
</div>
|
|
<div class="lab-note" style="padding-left:8px;">◎計算方式：總膽固醇－高密度脂蛋白膽固醇－（三酸甘油脂÷5）</div>
|
|
<div class="lab-note" style="padding-left:8px;">◎計算方式：男性：186×（血清肌酸酐）<sup>-1.154</sup>×（年齡）<sup>-0.203</sup> 女性：186×（血清肌酸酐）<sup>-1.154</sup>×（年齡）<sup>-0.203</sup>×0.742</div>
|
|
</div>
|
|
<!-- B/C 肝 -->
|
|
<div class="lab-section" style="border-bottom:none;">
|
|
<div style="display:flex; flex-wrap:wrap; gap:24px; align-items:center;">
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>B 型肝炎表面抗原（HBsAg）：</span>
|
|
<span class="opt"><input type="radio" name="f_hepatitis.f40_hbsag.result" value="陰性" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_hepatitis.f40_hbsag.result" data-match-value="negative"> 陰性</span>
|
|
<span class="opt"><input type="radio" name="f_hepatitis.f40_hbsag.result" value="陽性" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_hepatitis.f40_hbsag.result" data-match-value="positive"> 陽性</span>
|
|
<span class="opt"><input type="radio" name="f_hepatitis.f40_hbsag.result" value="未執行" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_hepatitis.f40_hbsag.result" data-match-value="not_done"> 未執行</span>
|
|
</span>
|
|
<span class="field-group" style="gap:8px;">
|
|
<span>C 型肝炎抗體（Anti-HCV）：</span>
|
|
<span class="opt"><input type="radio" name="f_hepatitis.f41_antihcv.result" value="陰性" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_hepatitis.f41_antihcv.result" data-match-value="negative"> 陰性</span>
|
|
<span class="opt"><input type="radio" name="f_hepatitis.f41_antihcv.result" value="陽性" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_hepatitis.f41_antihcv.result" data-match-value="positive"> 陽性</span>
|
|
<span class="opt"><input type="radio" name="f_hepatitis.f41_antihcv.result" value="未執行" data-form-code="ADULT_HEALTH_CHECK_LABORATORY" data-answer-path="f_hepatitis.f41_antihcv.result" data-match-value="not_done"> 未執行</span>
|
|
</span>
|
|
</div>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
<!-- ===== 健康諮詢 ===== -->
|
|
<tr>
|
|
<td class="cat-label">健康諮詢</td>
|
|
<td>
|
|
<div class="check-group">
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="戒菸" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f42"> 戒菸</span>
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="節酒" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f43"> 節酒</span>
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="戒檳榔" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f44"> 戒檳榔</span>
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="規律運動" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f45"> 規律運動（含 150 分鐘/每週）</span>
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="維持正常體重" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f46"> 維持正常體重</span>
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="健康飲食" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f47"> 健康飲食（含我的健康餐盤）</span>
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="事故傷害預防" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f48"> 事故傷害預防</span>
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="口腔保健" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f49"> 口腔保健</span>
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="慢性疾病風險評估" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f50"> 慢性疾病風險評估</span>
|
|
<span class="opt"><input type="checkbox" name="nr_counseling" value="腎病識能衛教指導" data-form-code="ADULT_HEALTH_CHECK_COUNSELING" data-answer-path="nr_counseling" data-match-value="f51"> 腎病識能衛教指導（含尿蛋白、eGFR 的數據、腎功能期別及其嚴重度、危險因子衛教）</span>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
<!-- ===== 檢查結果與建議 ===== -->
|
|
<tr>
|
|
<td class="cat-label">檢查結果<br>與建議</td>
|
|
<td style="padding:0;">
|
|
<div class="result-row" style="font-size:9px; color:#6a7282;">身體檢查部分：</div>
|
|
<div class="result-row">
|
|
<div class="result-label">血 壓：</div>
|
|
<div class="result-options">
|
|
<span class="opt"><input type="radio" name="f_exam_results.f50_bp.code" value="正常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f50_bp.code" data-match-value="1"> 正常</span>
|
|
<span class="opt"><input type="radio" name="f_exam_results.f50_bp.code" value="異常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f50_bp.code" data-match-values="2,3,4"> 異常：建議</span>
|
|
<span class="field-group"><span class="opt"><input type="checkbox" name="f_exam_results.f50_bp.code_detail" value="生活型態" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f50_bp.code" data-match-value="2"> 生活型態改善，並定期</span><input type="text" style="--field-min-width:30px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f50_bp.months"><span>個月追蹤</span></span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f50_bp.code_detail" value="進一步檢查" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f50_bp.code" data-match-value="3"> 進一步檢查</span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f50_bp.code_detail" value="接受治療" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f50_bp.code" data-match-value="4"> 接受治療</span>
|
|
</div>
|
|
</div>
|
|
<div class="result-row">
|
|
<div class="result-label">飯前血糖：</div>
|
|
<div class="result-options">
|
|
<span class="opt"><input type="radio" name="f_exam_results.f51_glucose.code" value="正常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f51_glucose.code" data-match-value="1"> 正常</span>
|
|
<span class="opt"><input type="radio" name="f_exam_results.f51_glucose.code" value="異常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f51_glucose.code" data-match-values="2,3,4"> 異常：建議</span>
|
|
<span class="field-group"><span class="opt"><input type="checkbox" name="f_exam_results.f51_glucose.code_detail" value="生活型態" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f51_glucose.code" data-match-value="2"> 生活型態改善，並定期</span><input type="text" style="--field-min-width:30px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f51_glucose.months"><span>個月追蹤</span></span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f51_glucose.code_detail" value="進一步檢查" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f51_glucose.code" data-match-value="3"> 進一步檢查</span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f51_glucose.code_detail" value="接受治療" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f51_glucose.code" data-match-value="4"> 接受治療</span>
|
|
</div>
|
|
</div>
|
|
<div class="result-row">
|
|
<div class="result-label">血脂肪：</div>
|
|
<div class="result-options">
|
|
<span class="opt"><input type="radio" name="f_exam_results.f52_lipid.code" value="正常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f52_lipid.code" data-match-value="1"> 正常</span>
|
|
<span class="opt"><input type="radio" name="f_exam_results.f52_lipid.code" value="異常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f52_lipid.code" data-match-values="2,3,4"> 異常：建議</span>
|
|
<span class="field-group"><span class="opt"><input type="checkbox" name="f_exam_results.f52_lipid.code_detail" value="生活型態" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f52_lipid.code" data-match-value="2"> 生活型態改善，並定期</span><input type="text" style="--field-min-width:30px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f52_lipid.months"><span>個月追蹤</span></span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f52_lipid.code_detail" value="進一步檢查" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f52_lipid.code" data-match-value="3"> 進一步檢查</span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f52_lipid.code_detail" value="接受治療" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f52_lipid.code" data-match-value="4"> 接受治療</span>
|
|
</div>
|
|
</div>
|
|
<div class="result-row">
|
|
<div class="result-label">腎功能：</div>
|
|
<div class="result-options">
|
|
<span class="opt"><input type="radio" name="f_exam_results.f53_renal.code" value="正常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f53_renal.code" data-match-value="1"> 正常</span>
|
|
<span class="field-group"><span class="opt"><input type="radio" name="f_exam_results.f53_renal.code" value="異常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f53_renal.code" data-match-values="2,3,4"> 異常：期別</span><input type="text" style="--field-min-width:30px;" data-source="unmapped" data-output-field="renal_stage"></span>
|
|
<span>建議</span>
|
|
<span class="field-group"><span class="opt"><input type="checkbox" name="f_exam_results.f53_renal.code_detail" value="生活型態" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f53_renal.code" data-match-value="2"> 生活型態改善，並定期</span><input type="text" style="--field-min-width:30px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f53_renal.months"><span>個月追蹤</span></span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f53_renal.code_detail" value="進一步檢查" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f53_renal.code" data-match-value="3"> 進一步檢查</span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f53_renal.code_detail" value="接受治療" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f53_renal.code" data-match-value="4"> 接受治療</span>
|
|
</div>
|
|
</div>
|
|
<div class="result-row">
|
|
<div class="result-label">肝功能：</div>
|
|
<div class="result-options">
|
|
<span class="opt"><input type="radio" name="f_exam_results.f54_liver.code" value="正常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f54_liver.code" data-match-value="1"> 正常</span>
|
|
<span class="opt"><input type="radio" name="f_exam_results.f54_liver.code" value="異常" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f54_liver.code" data-match-values="2,3,4"> 異常：建議</span>
|
|
<span class="field-group"><span class="opt"><input type="checkbox" name="f_exam_results.f54_liver.code_detail" value="生活型態" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f54_liver.code" data-match-value="2"> 生活型態改善，並定期</span><input type="text" style="--field-min-width:30px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f54_liver.months"><span>個月追蹤</span></span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f54_liver.code_detail" value="進一步檢查" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f54_liver.code" data-match-value="3"> 進一步檢查</span>
|
|
<span class="opt"><input type="checkbox" name="f_exam_results.f54_liver.code_detail" value="接受治療" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_exam_results.f54_liver.code" data-match-value="4"> 接受治療</span>
|
|
</div>
|
|
</div>
|
|
<div class="result-row">
|
|
<div class="result-label">代謝症候群：</div>
|
|
<div class="result-options">
|
|
<span class="opt"><input type="radio" name="f_mets_result.f55_mets.has_mets" value="沒有" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_mets_result.f55_mets.has_mets" data-match-value="no"> 沒有</span>
|
|
<span class="opt"><input type="radio" name="f_mets_result.f55_mets.has_mets" value="有" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_mets_result.f55_mets.has_mets" data-match-value="yes"> 有：建議</span>
|
|
<span class="field-group"><span class="opt"><input type="checkbox" name="f_mets_result.f55_mets.code" value="生活型態" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_mets_result.f55_mets.code" data-match-value="2"> 生活型態改善，並定期</span><input type="text" style="--field-min-width:30px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_mets_result.f55_mets.months"><span>個月追蹤</span></span>
|
|
<span class="opt"><input type="checkbox" name="f_mets_result.f55_mets.code" value="進一步檢查" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_mets_result.f55_mets.code" data-match-value="3"> 進一步檢查</span>
|
|
<span class="opt"><input type="checkbox" name="f_mets_result.f55_mets.code" value="接受治療" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_mets_result.f55_mets.code" data-match-value="4"> 接受治療</span>
|
|
</div>
|
|
</div>
|
|
<div class="result-row" style="font-size:8.5px; color:#6a7282;">（代謝症候群定義：腰圍、血壓、空腹血糖、三酸甘油脂、高密度脂蛋白膽固醇，其中三項或超過三項異常）</div>
|
|
<div class="result-row">
|
|
<div style="width:100%;">
|
|
<div style="margin-bottom:8px;">慢性疾病風險值：</div>
|
|
<div style="display:flex; flex-wrap:wrap; gap:16px; padding-left:8px;">
|
|
<span class="field-group"><span>冠心病（1.</span><input type="text" style="--field-min-width:40px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_chronic_risk.f66_chd.value" data-applicability-path="f_chronic_risk.f66_chd.applicable"><span>%；2.不適用）</span></span>
|
|
<span class="field-group"><span>糖尿病（1.</span><input type="text" style="--field-min-width:40px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_chronic_risk.f67_dm.value" data-applicability-path="f_chronic_risk.f67_dm.applicable"><span>%；2.不適用）</span></span>
|
|
<span class="field-group"><span>高血壓（1.</span><input type="text" style="--field-min-width:40px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_chronic_risk.f68_htn.value" data-applicability-path="f_chronic_risk.f68_htn.applicable"><span>；2.不適用）</span></span>
|
|
<span class="field-group"><span>腦中風（1.</span><input type="text" style="--field-min-width:40px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_chronic_risk.f69_stroke.value" data-applicability-path="f_chronic_risk.f69_stroke.applicable"><span>%；2.不適用）</span></span>
|
|
<span class="field-group"><span>心血管不良事件（1.</span><input type="text" style="--field-min-width:40px;" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_chronic_risk.f70_cvd.value" data-applicability-path="f_chronic_risk.f70_cvd.applicable"><span>%；2.不適用）</span></span>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="result-row">
|
|
<div class="result-label">B 型肝炎表面抗原：</div>
|
|
<div class="result-options">
|
|
<span class="opt"><input type="radio" name="f_hep_result.f56_hbv.code" value="陰性" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_hep_result.f56_hbv.code" data-match-value="negative"> 陰性</span>
|
|
<span class="opt"><input type="radio" name="f_hep_result.f56_hbv.code" value="陽性" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_hep_result.f56_hbv.code" data-match-value="positive"> 陽性</span>
|
|
<span class="opt"><input type="radio" name="f_hep_result.f56_hbv.code" value="進一步檢查" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_hep_result.f56_hbv.code" data-match-value="further"> 進一步檢查</span>
|
|
<span class="opt"><input type="radio" name="f_hep_result.f56_hbv.code" value="接受治療" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_hep_result.f56_hbv.code" data-match-value="treat"> 接受治療</span>
|
|
</div>
|
|
</div>
|
|
<div class="result-row">
|
|
<div class="result-label">C 型肝炎抗體：</div>
|
|
<div class="result-options">
|
|
<span class="opt"><input type="radio" name="f_hep_result.f57_hcv.code" value="陰性" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_hep_result.f57_hcv.code" data-match-value="negative"> 陰性</span>
|
|
<span class="opt"><input type="radio" name="f_hep_result.f57_hcv.code" value="陽性" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_hep_result.f57_hcv.code" data-match-value="positive"> 陽性</span>
|
|
<span class="opt"><input type="radio" name="f_hep_result.f57_hcv.code" value="進一步檢查" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_hep_result.f57_hcv.code" data-match-value="further"> 進一步檢查</span>
|
|
<span class="opt"><input type="radio" name="f_hep_result.f57_hcv.code" value="接受治療" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="f_hep_result.f57_hcv.code" data-match-value="treat"> 接受治療</span>
|
|
</div>
|
|
</div>
|
|
<div class="result-row" style="border-bottom:none;">
|
|
<div class="result-label">咳嗽症狀：</div>
|
|
<div class="result-options">
|
|
<span class="opt"><input type="radio" name="nr_cough_result" value="沒有" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="nr_cough_result" data-match-value="no"> 沒有</span>
|
|
<span class="opt"><input type="radio" name="nr_cough_result" value="有" data-form-code="ADULT_HEALTH_CHECK_RESULT" data-answer-path="nr_cough_result" data-match-value="yes"> 有：建議轉診進一步評估是否可能為結核病</span>
|
|
</div>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
<!-- ===== 老人健檢 ===== -->
|
|
<tr>
|
|
<td class="cat-label">老人<br>健檢</td>
|
|
<td style="padding:0;">
|
|
<!-- 心電圖 -->
|
|
<div class="line" style="gap:8px;">
|
|
<span style="white-space:nowrap;">心電圖</span>
|
|
<input type="text" style="flex:1; --field-min-width:200px; text-align:left;" data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.ecg">
|
|
</div>
|
|
<!-- 胸部 X 光 -->
|
|
<div class="line" style="align-items:flex-start; gap:8px;">
|
|
<span style="white-space:nowrap; padding-top:3px;">胸部 X 光</span>
|
|
<textarea data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.chest_xray"
|
|
style="flex:1; min-height:44px; max-height:200px; border:1px solid #d1d5dc; border-radius:3px; padding:3px 6px;
|
|
font-family:inherit; font-size:inherit; color:#364153; resize:vertical; outline:none; line-height:1.4; overflow-y:auto;"></textarea>
|
|
</div>
|
|
<!-- 血清白蛋白 -->
|
|
<div class="line">
|
|
<span style="white-space:nowrap;">血清白蛋白（albumin）</span>
|
|
<input type="text" style="--field-min-width:80px; text-align:left;" data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.albumin.value">
|
|
<span style="color:#6a7282;">g/dL</span>
|
|
<span class="field-group" style="margin-left:auto;"><span>參考值：</span><input type="text" style="--field-min-width:60px; text-align:left;" data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.albumin.ref" value="3.5 - 5.7"></span>
|
|
</div>
|
|
<!-- 醣化血色素 -->
|
|
<div class="line">
|
|
<span style="white-space:nowrap;">醣化血色素（HbA1c）</span>
|
|
<input type="text" style="--field-min-width:80px; text-align:left;" data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.hba1c.value">
|
|
<span style="color:#6a7282;">%</span>
|
|
<span class="field-group" style="margin-left:auto;"><span>參考值：</span><input type="text" style="--field-min-width:60px; text-align:left;" data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.hba1c.ref" value="4 - 6"></span>
|
|
</div>
|
|
<!-- 尿素氮 -->
|
|
<div class="line">
|
|
<span style="white-space:nowrap;">尿素氮（BUN）</span>
|
|
<input type="text" style="--field-min-width:80px; text-align:left;" data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.bun.value">
|
|
<span style="color:#6a7282;">mg/dl</span>
|
|
<span class="field-group" style="margin-left:auto;"><span>參考值：</span><input type="text" style="--field-min-width:60px; text-align:left;" data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.bun.ref" value="7 - 25"></span>
|
|
</div>
|
|
<!-- 糞便潛血檢查 -->
|
|
<div class="line" style="border-bottom:none;">
|
|
<span style="white-space:nowrap;">糞便潛血檢查</span>
|
|
<input type="text" style="--field-min-width:80px; text-align:left;" data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.fobt.value">
|
|
<span class="field-group" style="margin-left:auto;"><span>參考值：</span><input type="text" style="--field-min-width:60px; text-align:left;" data-form-code="ELDERLY_HEALTH_CHECK" data-answer-path="elderly.fobt.ref" value="陰性"></span>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
|
|
<tr>
|
|
<td class="cat-label">特約醫事<br>服務機構</td>
|
|
<td style="padding:0;">
|
|
<div class="inst-row">
|
|
<div class="inst-cell">
|
|
<div class="cell-title">醫院名稱（醫院代號）</div>
|
|
<div class="cell-value institution-inputs">
|
|
<input id="field-institutionName" type="text" class="w-lg" aria-label="醫院名稱" data-source="institution-snapshot" data-output-field="institution_name">
|
|
<span>（</span>
|
|
<input id="field-institutionCode" type="text" class="w-xs" aria-label="醫院代號" data-source="institution-snapshot" data-output-field="institution_code">
|
|
<span>）</span>
|
|
</div>
|
|
</div>
|
|
<div class="inst-cell">
|
|
<div class="cell-title">地址 / 電話</div>
|
|
<div class="cell-value institution-inputs institution-contact-inputs">
|
|
<input id="field-institutionAddress" type="text" class="w-lg" aria-label="醫院地址" data-source="institution-snapshot" data-output-field="institution_address">
|
|
<span class="institution-phone-row">
|
|
<span>（</span>
|
|
<input id="field-institutionPhoneAreaCode" type="text" value="" aria-label="電話區號" data-source="institution-snapshot" data-output-field="institution_phone_area_code">
|
|
<span>）</span>
|
|
<input id="field-institutionPhone" type="text" class="w-md" aria-label="醫院電話" data-source="institution-snapshot" data-output-field="institution_phone">
|
|
</span>
|
|
</div>
|
|
</div>
|
|
<div class="inst-cell">
|
|
<div class="cell-title">檢查醫師簽名（蓋章）</div>
|
|
<div class="sign-line"></div>
|
|
</div>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<!-- Footer -->
|
|
<div class="footer-notes">
|
|
<p>※ 服務對象如有任何不適異狀、曾患疾病或目前病症，務必於問診時詳細告知醫師。</p>
|
|
<p>第一聯 特約醫事服務機構通知保險對象檢查結果聯。</p>
|
|
<p>第二聯 特約醫事服務機構留存聯（本資料請留存於病歷）。</p>
|
|
<div>
|
|
<p>※ 服務對象如為特約醫事檢驗機構依雙軌作業方式提供第一階段檢驗檢查服務者，其自行選定第二階段服務之特約醫事服務機構名稱：</p>
|
|
<div style="display:flex; align-items:center; gap:4px; padding-top:2px;">
|
|
<input type="text" class="w-xxl" data-source="case-record" data-output-field="second_stage_institution_name">
|
|
<span>地址：</span>
|
|
<input type="text" class="w-xxl" data-source="case-record" data-output-field="second_stage_institution_address">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<!-- Page 4: 衛教建議 -->
|
|
<div class="page2-wrapper form-page">
|
|
<div class="edu-box">
|
|
<div class="edu-title">衛教建議</div>
|
|
<div class="edu-content" contenteditable="true" style="outline:none;"></div>
|
|
</div>
|
|
</div>
|
|
|
|
</body>
|
|
</html>
|