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