{
  "locale": "zh-tw",
  "title": "健康署「糞便抗原檢測胃幽門螺旋桿菌服務」管理紀錄表",
  "description": "本項經費由衛生福利部國民健康署運用菸品健康福利捐／公務預算補助",
  "completedHtml": "<h3>表單填寫完成</h3>",
  "pages": [
    {
      "name": "exam_info",
      "title": "檢查資訊",
      "elements": [
        {
          "type": "checkbox",
          "name": "payment_method",
          "title": "支付方式",
          "isRequired": true,
          "choices": [
            {
              "value": "preventive",
              "text": "預防保健"
            },
            {
              "value": "nhi",
              "text": "健保醫療給付"
            },
            {
              "value": "other_subsidy",
              "text": "其他公務預算補助"
            },
            {
              "value": "self_pay",
              "text": "自費健康檢查"
            },
            {
              "value": "other",
              "text": "其他"
            }
          ],
          "colCount": 3
        },
        {
          "type": "text",
          "name": "institution_name",
          "title": "採檢單位",
          "defaultValue": "亞洲大學附屬醫院",
          "isRequired": true
        },
        {
          "type": "text",
          "name": "institution_code",
          "startWithNewLine": false,
          "title": "醫事機構代碼",
          "defaultValue": "1303180011",
          "isRequired": true
        }
      ]
    },
    {
      "name": "basic_info",
      "title": "基本資料",
      "elements": [
        {
          "type": "text",
          "name": "patient_name",
          "title": "姓名",
          "isRequired": true,
          "placeholder": "請輸入姓名"
        },
        {
          "type": "radiogroup",
          "name": "gender",
          "startWithNewLine": false,
          "title": "性別",
          "isRequired": true,
          "choices": [
            {
              "value": "male",
              "text": "男"
            },
            {
              "value": "female",
              "text": "女"
            }
          ],
          "colCount": 2
        },
        {
          "type": "radiogroup",
          "name": "is_indigenous",
          "title": "原住民",
          "isRequired": true,
          "choices": [
            {
              "value": "no",
              "text": "否"
            },
            {
              "value": "yes",
              "text": "是"
            }
          ],
          "colCount": 2
        },
        {
          "type": "text",
          "name": "indigenous_tribe",
          "visibleIf": "{is_indigenous} = 'yes'",
          "startWithNewLine": false,
          "title": "族別",
          "isRequired": true,
          "placeholder": "請輸入族別"
        },
        {
          "type": "text",
          "name": "id_number",
          "title": "身分證字號",
          "isRequired": true,
          "placeholder": "身分證字號或居留證號"
        },
        {
          "type": "panel",
          "name": "birth_date_panel",
          "title": "出生日期",
          "elements": [
            {
              "type": "text",
              "name": "birth_year",
              "title": "年（民國）",
              "isRequired": true,
              "inputType": "number",
              "min": 1,
              "max": 150,
              "placeholder": "民國年"
            },
            {
              "type": "dropdown",
              "name": "birth_month",
              "startWithNewLine": false,
              "title": "月份",
              "isRequired": true,
              "choices": [
                {
                  "value": 1,
                  "text": "1 月"
                },
                {
                  "value": 2,
                  "text": "2 月"
                },
                {
                  "value": 3,
                  "text": "3 月"
                },
                {
                  "value": 4,
                  "text": "4 月"
                },
                {
                  "value": 5,
                  "text": "5 月"
                },
                {
                  "value": 6,
                  "text": "6 月"
                },
                {
                  "value": 7,
                  "text": "7 月"
                },
                {
                  "value": 8,
                  "text": "8 月"
                },
                {
                  "value": 9,
                  "text": "9 月"
                },
                {
                  "value": 10,
                  "text": "10 月"
                },
                {
                  "value": 11,
                  "text": "11 月"
                },
                {
                  "value": 12,
                  "text": "12 月"
                }
              ],
              "placeholder": "請選擇月份"
            },
            {
              "type": "dropdown",
              "name": "birth_day",
              "startWithNewLine": false,
              "title": "日期",
              "isRequired": true,
              "choices": [
                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": "panel",
          "name": "visit_date_panel",
          "title": "門診日期",
          "elements": [
            {
              "type": "text",
              "name": "visit_year",
              "title": "年（民國）",
              "isRequired": true,
              "inputType": "number",
              "min": 1,
              "max": 150,
              "placeholder": "民國年"
            },
            {
              "type": "dropdown",
              "name": "visit_month",
              "startWithNewLine": false,
              "title": "月份",
              "isRequired": true,
              "choices": [
                {
                  "value": 1,
                  "text": "1 月"
                },
                {
                  "value": 2,
                  "text": "2 月"
                },
                {
                  "value": 3,
                  "text": "3 月"
                },
                {
                  "value": 4,
                  "text": "4 月"
                },
                {
                  "value": 5,
                  "text": "5 月"
                },
                {
                  "value": 6,
                  "text": "6 月"
                },
                {
                  "value": 7,
                  "text": "7 月"
                },
                {
                  "value": 8,
                  "text": "8 月"
                },
                {
                  "value": 9,
                  "text": "9 月"
                },
                {
                  "value": 10,
                  "text": "10 月"
                },
                {
                  "value": 11,
                  "text": "11 月"
                },
                {
                  "value": 12,
                  "text": "12 月"
                }
              ],
              "placeholder": "請選擇月份"
            },
            {
              "type": "dropdown",
              "name": "visit_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": "html",
          "name": "second_visit_note",
          "html": "<p style='color:#666; font-size:0.9em;'>若糞便抗原檢測首次檢驗結果為「檢測失效」，請填寫第二次門診日期</p>"
        },
        {
          "type": "panel",
          "name": "second_visit_date_panel",
          "title": "第二次門診日期（檢測失效時填寫）",
          "elements": [
            {
              "type": "text",
              "name": "second_visit_year",
              "title": "年（民國）",
              "inputType": "number",
              "min": 1,
              "max": 150,
              "placeholder": "民國年"
            },
            {
              "type": "dropdown",
              "name": "second_visit_month",
              "startWithNewLine": false,
              "title": "月份",
              "choices": [
                {
                  "value": 1,
                  "text": "1 月"
                },
                {
                  "value": 2,
                  "text": "2 月"
                },
                {
                  "value": 3,
                  "text": "3 月"
                },
                {
                  "value": 4,
                  "text": "4 月"
                },
                {
                  "value": 5,
                  "text": "5 月"
                },
                {
                  "value": 6,
                  "text": "6 月"
                },
                {
                  "value": 7,
                  "text": "7 月"
                },
                {
                  "value": 8,
                  "text": "8 月"
                },
                {
                  "value": 9,
                  "text": "9 月"
                },
                {
                  "value": 10,
                  "text": "10 月"
                },
                {
                  "value": 11,
                  "text": "11 月"
                },
                {
                  "value": 12,
                  "text": "12 月"
                }
              ],
              "placeholder": "請選擇月份"
            },
            {
              "type": "dropdown",
              "name": "second_visit_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": "text",
          "name": "phone",
          "title": "聯絡電話",
          "placeholder": "區碼 + 電話號碼"
        },
        {
          "type": "text",
          "name": "mobile",
          "startWithNewLine": false,
          "title": "手機",
          "placeholder": "手機號碼"
        },
        {
          "type": "radiogroup",
          "name": "religion",
          "title": "宗教",
          "choices": [
            {
              "value": "none",
              "text": "無"
            },
            {
              "value": "catholic",
              "text": "天主教"
            },
            {
              "value": "christian",
              "text": "基督教"
            },
            {
              "value": "buddhism",
              "text": "佛教"
            },
            {
              "value": "taoism",
              "text": "道教"
            },
            {
              "value": "yiguandao",
              "text": "一貫道"
            }
          ],
          "showOtherItem": true,
          "otherPlaceholder": "請輸入宗教",
          "otherText": "其他",
          "colCount": 4
        },
        {
          "type": "panel",
          "name": "address_panel",
          "title": "現居住地址",
          "elements": [
            {
              "type": "text",
              "name": "address_district_code",
              "title": "鄉鎮市區代碼",
              "placeholder": "四碼代碼"
            },
            {
              "type": "dropdown",
              "name": "address_county",
              "startWithNewLine": false,
              "title": "縣市",
              "choices": [
                "臺北市",
                "新北市",
                "桃園市",
                "臺中市",
                "臺南市",
                "高雄市",
                "基隆市",
                "新竹市",
                "嘉義市",
                "新竹縣",
                "苗栗縣",
                "彰化縣",
                "南投縣",
                "雲林縣",
                "嘉義縣",
                "屏東縣",
                "宜蘭縣",
                "花蓮縣",
                "臺東縣",
                "澎湖縣",
                "金門縣",
                "連江縣"
              ],
              "placeholder": "請選擇縣市"
            },
            {
              "type": "text",
              "name": "address_detail",
              "title": "詳細地址",
              "placeholder": "鄉鎮市區、村里、路街、段巷弄號樓"
            }
          ]
        },
        {
          "type": "radiogroup",
          "name": "education",
          "title": "教育",
          "isRequired": true,
          "choices": [
            {
              "value": "none",
              "text": "無"
            },
            {
              "value": "elementary",
              "text": "小學"
            },
            {
              "value": "junior_high",
              "text": "國（初）中"
            },
            {
              "value": "senior_high",
              "text": "高中（職）"
            },
            {
              "value": "college",
              "text": "專科、大學"
            },
            {
              "value": "graduate",
              "text": "研究所以上"
            },
            {
              "value": "refused",
              "text": "拒答"
            }
          ],
          "colCount": 4
        },
        {
          "type": "radiogroup",
          "name": "has_job",
          "title": "職業",
          "isRequired": true,
          "choices": [
            {
              "value": "yes",
              "text": "有"
            },
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "refused",
              "text": "拒答"
            }
          ],
          "colCount": 3
        },
        {
          "type": "text",
          "name": "job_title",
          "visibleIf": "{has_job} = 'yes'",
          "title": "職業名稱",
          "isRequired": true,
          "placeholder": "請輸入職業"
        },
        {
          "type": "radiogroup",
          "name": "marital_status",
          "title": "婚姻狀況",
          "isRequired": true,
          "choices": [
            {
              "value": "single",
              "text": "未婚"
            },
            {
              "value": "married",
              "text": "已婚"
            },
            {
              "value": "other",
              "text": "其他"
            }
          ],
          "colCount": 3
        }
      ]
    },
    {
      "name": "personal_history",
      "title": "個人病史",
      "elements": [
        {
          "type": "checkbox",
          "name": "personal_disease_history",
          "title": "1. 個人（曾經）疾病史",
          "isRequired": true,
          "choices": [
            {
              "value": "gastritis",
              "text": "胃炎"
            },
            {
              "value": "gastric_ulcer",
              "text": "胃潰瘍"
            },
            {
              "value": "duodenal_ulcer",
              "text": "十二指腸潰瘍"
            },
            {
              "value": "gerd",
              "text": "胃食道逆流"
            },
            {
              "value": "gastric_tumor",
              "text": "胃腫瘤"
            },
            {
              "value": "gastric_cancer",
              "text": "胃癌"
            },
            {
              "value": "hp_infection",
              "text": "胃幽門桿菌感染"
            }
          ],
          "showOtherItem": true,
          "showNoneItem": true,
          "otherPlaceholder": "請說明其他疾病",
          "noneText": "無",
          "otherText": "其他",
          "colCount": 3
        },
        {
          "type": "panel",
          "name": "disease_onset_panel",
          "visibleIf": "{personal_disease_history} notempty and {personal_disease_history} notcontains 'none'",
          "title": "發病年份",
          "elements": [
            {
              "type": "text",
              "name": "disease_onset_year",
              "visibleIf": "{disease_onset_unknown} empty",
              "title": "民國年",
              "inputType": "number",
              "min": 1,
              "max": 150,
              "placeholder": "民國年"
            },
            {
              "type": "checkbox",
              "name": "disease_onset_unknown",
              "startWithNewLine": false,
              "titleLocation": "hidden",
              "choices": [
                {
                  "value": "unknown",
                  "text": "不詳"
                }
              ]
            }
          ]
        },
        {
          "type": "radiogroup",
          "name": "hp_eradication",
          "title": "2. 曾接受胃幽門桿菌除菌治療",
          "isRequired": true,
          "choices": [
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 2
        },
        {
          "type": "radiogroup",
          "name": "gastroscopy",
          "title": "3. 曾接受過胃鏡檢查",
          "isRequired": true,
          "choices": [
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 2
        },
        {
          "type": "panel",
          "name": "gastroscopy_year_panel",
          "visibleIf": "{gastroscopy} = 'yes'",
          "title": "胃鏡檢查年份",
          "elements": [
            {
              "type": "text",
              "name": "gastroscopy_year",
              "visibleIf": "{gastroscopy_year_unknown} empty",
              "title": "民國年",
              "inputType": "number",
              "min": 1,
              "max": 150,
              "placeholder": "民國年"
            },
            {
              "type": "checkbox",
              "name": "gastroscopy_year_unknown",
              "startWithNewLine": false,
              "titleLocation": "hidden",
              "choices": [
                {
                  "value": "unknown",
                  "text": "不詳"
                }
              ]
            }
          ]
        },
        {
          "type": "radiogroup",
          "name": "ppi_usage",
          "title": "4. 近一個月內是否使用潰瘍／胃食道逆流特效藥（一日一顆）",
          "isRequired": true,
          "choices": [
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 2
        },
        {
          "type": "radiogroup",
          "name": "drug_allergy",
          "title": "5. 藥物過敏",
          "isRequired": true,
          "choices": [
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 2
        },
        {
          "type": "text",
          "name": "drug_allergy_detail",
          "visibleIf": "{drug_allergy} = 'yes'",
          "title": "藥物名稱",
          "isRequired": true,
          "placeholder": "請輸入藥物名稱"
        }
      ]
    },
    {
      "name": "family_history",
      "title": "家族病史",
      "elements": [
        {
          "type": "radiogroup",
          "name": "family_hp",
          "title": "1. 幽門桿菌家族史",
          "isRequired": true,
          "choices": [
            {
              "value": "unknown",
              "text": "不詳"
            },
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 3
        },
        {
          "type": "checkbox",
          "name": "family_hp_members",
          "visibleIf": "{family_hp} = 'yes'",
          "title": "幽門桿菌家族成員（可複選）",
          "isRequired": true,
          "choices": [
            {
              "value": "father",
              "text": "父"
            },
            {
              "value": "mother",
              "text": "母"
            },
            {
              "value": "spouse",
              "text": "夫妻"
            },
            {
              "value": "siblings",
              "text": "兄弟姊妹"
            },
            {
              "value": "children",
              "text": "子女"
            },
            {
              "value": "other",
              "text": "其他"
            }
          ],
          "colCount": 3
        },
        {
          "type": "text",
          "name": "family_hp_siblings_count",
          "visibleIf": "{family_hp} = 'yes' and {family_hp_members} contains 'siblings'",
          "title": "兄弟姊妹人數",
          "inputType": "number",
          "min": 1,
          "placeholder": "人數"
        },
        {
          "type": "text",
          "name": "family_hp_children_count",
          "visibleIf": "{family_hp} = 'yes' and {family_hp_members} contains 'children'",
          "startWithNewLine": false,
          "title": "子女人數",
          "inputType": "number",
          "min": 1,
          "placeholder": "人數"
        },
        {
          "type": "text",
          "name": "family_hp_other_detail",
          "visibleIf": "{family_hp} = 'yes' and {family_hp_members} contains 'other'",
          "title": "其他親屬說明",
          "placeholder": "請說明"
        },
        {
          "type": "text",
          "name": "family_hp_other_count",
          "visibleIf": "{family_hp} = 'yes' and {family_hp_members} contains 'other'",
          "startWithNewLine": false,
          "title": "人數",
          "inputType": "number",
          "min": 1,
          "placeholder": "人數"
        },
        {
          "type": "radiogroup",
          "name": "family_peptic_ulcer",
          "title": "2. 消化性潰瘍家族史（胃或十二指腸）",
          "isRequired": true,
          "choices": [
            {
              "value": "unknown",
              "text": "不詳"
            },
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 3
        },
        {
          "type": "checkbox",
          "name": "family_peptic_ulcer_members",
          "visibleIf": "{family_peptic_ulcer} = 'yes'",
          "title": "消化性潰瘍家族成員（可複選）",
          "isRequired": true,
          "choices": [
            {
              "value": "father",
              "text": "父"
            },
            {
              "value": "mother",
              "text": "母"
            },
            {
              "value": "spouse",
              "text": "夫妻"
            },
            {
              "value": "siblings",
              "text": "兄弟姊妹"
            },
            {
              "value": "children",
              "text": "子女"
            },
            {
              "value": "other",
              "text": "其他"
            }
          ],
          "colCount": 3
        },
        {
          "type": "text",
          "name": "family_peptic_ulcer_siblings_count",
          "visibleIf": "{family_peptic_ulcer} = 'yes' and {family_peptic_ulcer_members} contains 'siblings'",
          "title": "兄弟姊妹人數",
          "inputType": "number",
          "min": 1,
          "placeholder": "人數"
        },
        {
          "type": "text",
          "name": "family_peptic_ulcer_children_count",
          "visibleIf": "{family_peptic_ulcer} = 'yes' and {family_peptic_ulcer_members} contains 'children'",
          "startWithNewLine": false,
          "title": "子女人數",
          "inputType": "number",
          "min": 1,
          "placeholder": "人數"
        },
        {
          "type": "text",
          "name": "family_peptic_ulcer_other_detail",
          "visibleIf": "{family_peptic_ulcer} = 'yes' and {family_peptic_ulcer_members} contains 'other'",
          "title": "其他親屬說明",
          "placeholder": "請說明"
        },
        {
          "type": "text",
          "name": "family_peptic_ulcer_other_count",
          "visibleIf": "{family_peptic_ulcer} = 'yes' and {family_peptic_ulcer_members} contains 'other'",
          "startWithNewLine": false,
          "title": "人數",
          "inputType": "number",
          "min": 1,
          "placeholder": "人數"
        },
        {
          "type": "radiogroup",
          "name": "family_gastric_cancer",
          "title": "3. 胃癌家族史",
          "isRequired": true,
          "choices": [
            {
              "value": "unknown",
              "text": "不詳"
            },
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 3
        },
        {
          "type": "checkbox",
          "name": "family_gastric_cancer_members",
          "visibleIf": "{family_gastric_cancer} = 'yes'",
          "title": "胃癌家族成員（可複選）",
          "isRequired": true,
          "choices": [
            {
              "value": "father",
              "text": "父"
            },
            {
              "value": "mother",
              "text": "母"
            },
            {
              "value": "spouse",
              "text": "夫妻"
            },
            {
              "value": "siblings",
              "text": "兄弟姊妹"
            },
            {
              "value": "children",
              "text": "子女"
            },
            {
              "value": "other",
              "text": "其他"
            }
          ],
          "colCount": 3
        },
        {
          "type": "text",
          "name": "family_gc_siblings_count",
          "visibleIf": "{family_gastric_cancer} = 'yes' and {family_gastric_cancer_members} contains 'siblings' and {family_gc_siblings_unknown} empty",
          "title": "兄弟姊妹人數",
          "inputType": "number",
          "min": 1,
          "placeholder": "人數"
        },
        {
          "type": "checkbox",
          "name": "family_gc_siblings_unknown",
          "visibleIf": "{family_gastric_cancer} = 'yes' and {family_gastric_cancer_members} contains 'siblings'",
          "startWithNewLine": false,
          "titleLocation": "hidden",
          "choices": [
            {
              "value": "unknown",
              "text": "不詳"
            }
          ]
        },
        {
          "type": "text",
          "name": "family_gc_children_count",
          "visibleIf": "{family_gastric_cancer} = 'yes' and {family_gastric_cancer_members} contains 'children' and {family_gc_children_unknown} empty",
          "title": "子女人數",
          "inputType": "number",
          "min": 1,
          "placeholder": "人數"
        },
        {
          "type": "checkbox",
          "name": "family_gc_children_unknown",
          "visibleIf": "{family_gastric_cancer} = 'yes' and {family_gastric_cancer_members} contains 'children'",
          "startWithNewLine": false,
          "titleLocation": "hidden",
          "choices": [
            {
              "value": "unknown",
              "text": "不詳"
            }
          ]
        },
        {
          "type": "text",
          "name": "family_gc_other_detail",
          "visibleIf": "{family_gastric_cancer} = 'yes' and {family_gastric_cancer_members} contains 'other'",
          "title": "其他親屬說明",
          "placeholder": "請說明"
        },
        {
          "type": "text",
          "name": "family_gc_other_count",
          "visibleIf": "{family_gastric_cancer} = 'yes' and {family_gastric_cancer_members} contains 'other' and {family_gc_other_unknown} empty",
          "startWithNewLine": false,
          "title": "人數",
          "inputType": "number",
          "min": 1,
          "placeholder": "人數"
        },
        {
          "type": "checkbox",
          "name": "family_gc_other_unknown",
          "visibleIf": "{family_gastric_cancer} = 'yes' and {family_gastric_cancer_members} contains 'other'",
          "startWithNewLine": false,
          "titleLocation": "hidden",
          "choices": [
            {
              "value": "unknown",
              "text": "不詳"
            }
          ]
        }
      ]
    },
    {
      "name": "medication_history",
      "title": "用藥史",
      "elements": [
        {
          "type": "radiogroup",
          "name": "recent_medication",
          "title": "最近三個月有無服用下列藥物",
          "isRequired": true,
          "choices": [
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 2
        },
        {
          "type": "checkbox",
          "name": "medication_types",
          "visibleIf": "{recent_medication} = 'yes'",
          "title": "藥物種類（可複選）",
          "isRequired": true,
          "choices": [
            {
              "value": "painkiller",
              "text": "止痛藥"
            },
            {
              "value": "steroid",
              "text": "類固醇"
            },
            {
              "value": "antiplatelet",
              "text": "抗血小板藥物"
            },
            {
              "value": "anticoagulant",
              "text": "抗凝血劑"
            },
            {
              "value": "diabetes",
              "text": "糖尿病用藥"
            },
            {
              "value": "iron",
              "text": "使用鐵劑治療貧血"
            }
          ],
          "colCount": 3
        },
        {
          "type": "checkbox",
          "name": "antiplatelet_detail",
          "visibleIf": "{medication_types} contains 'antiplatelet'",
          "title": "抗血小板藥物細項",
          "isRequired": true,
          "choices": [
            {
              "value": "aspirin",
              "text": "阿斯匹靈（aspirin）"
            },
            {
              "value": "plavix",
              "text": "保栓通（plavix）"
            }
          ],
          "showOtherItem": true,
          "otherPlaceholder": "請輸入藥物名稱",
          "otherText": "其他",
          "colCount": 3
        },
        {
          "type": "checkbox",
          "name": "anticoagulant_detail",
          "visibleIf": "{medication_types} contains 'anticoagulant'",
          "title": "抗凝血劑細項",
          "isRequired": true,
          "choices": [
            {
              "value": "coumadin",
              "text": "可邁丁（coumadin）"
            }
          ],
          "showOtherItem": true,
          "otherPlaceholder": "請輸入藥物名稱",
          "otherText": "其他",
          "colCount": 2
        },
        {
          "type": "checkbox",
          "name": "diabetes_detail",
          "visibleIf": "{medication_types} contains 'diabetes'",
          "title": "糖尿病用藥細項",
          "isRequired": true,
          "choices": [
            {
              "value": "oral",
              "text": "口服型控制血糖"
            },
            {
              "value": "insulin",
              "text": "注射型胰島素"
            }
          ],
          "colCount": 2
        }
      ]
    },
    {
      "name": "lifestyle",
      "title": "生活型態",
      "elements": [
        {
          "type": "radiogroup",
          "name": "smoking",
          "title": "1. 您有無吸菸習慣？",
          "isRequired": true,
          "choices": [
            {
              "value": "never",
              "text": "從不"
            },
            {
              "value": "quit",
              "text": "已戒"
            },
            {
              "value": "current",
              "text": "目前有吸"
            }
          ],
          "showOtherItem": true,
          "otherPlaceholder": "請說明",
          "otherText": "其他",
          "colCount": 4
        },
        {
          "type": "radiogroup",
          "name": "drinking",
          "title": "2. 您有無喝酒習慣？",
          "isRequired": true,
          "choices": [
            {
              "value": "never",
              "text": "從不"
            },
            {
              "value": "quit",
              "text": "已戒"
            },
            {
              "value": "current",
              "text": "目前有喝"
            }
          ],
          "showOtherItem": true,
          "otherPlaceholder": "請說明",
          "otherText": "其他",
          "colCount": 4
        },
        {
          "type": "radiogroup",
          "name": "betel_nut",
          "title": "3. 您有無嚼檳榔習慣？",
          "isRequired": true,
          "choices": [
            {
              "value": "never",
              "text": "從不"
            },
            {
              "value": "quit",
              "text": "已戒"
            },
            {
              "value": "current",
              "text": "目前有嚼"
            }
          ],
          "showOtherItem": true,
          "otherPlaceholder": "請說明",
          "otherText": "其他",
          "colCount": 4
        },
        {
          "type": "radiogroup",
          "name": "pickled_food",
          "title": "4. 您是否常常（每週 3 次或以上）食用醃漬食物如鹹魚、醬瓜、豆瓣醬、酸菜等？",
          "isRequired": true,
          "choices": [
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 2
        },
        {
          "type": "radiogroup",
          "name": "smoked_grilled_food",
          "title": "5. 您是否常常（每週 3 次或以上）食用煙燻、燒烤、高香料的肉類如香腸、烤肉等？",
          "isRequired": true,
          "choices": [
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 2
        },
        {
          "type": "radiogroup",
          "name": "raw_food",
          "title": "6. 您是否常常（每週 3 次或以上）食用生食如生肉、生魚等？",
          "isRequired": true,
          "choices": [
            {
              "value": "no",
              "text": "無"
            },
            {
              "value": "yes",
              "text": "有"
            }
          ],
          "colCount": 2
        }
      ]
    },
    {
      "name": "consent_confirm",
      "title": "同意聲明與確認",
      "elements": [
        {
          "type": "html",
          "name": "consent_text",
          "html": "<div style='background:#f8f9fa; padding:12px; border-radius:6px; border-left:4px solid #0d6efd; margin-bottom:12px;'><p>本人同意接受以糞便抗原檢測胃幽門螺旋桿菌檢查，相關資料將作為衛生單位政策評估或個案追蹤健康管理使用。</p></div>"
        },
        {
          "type": "checkbox",
          "name": "consent_agree",
          "title": "受檢者確認",
          "isRequired": true,
          "choices": [
            {
              "value": "agree",
              "text": "確認以上資料正確無誤"
            }
          ]
        },
        {
          "type": "html",
          "name": "upload_note",
          "html": "<p style='color:#666; font-size:0.85em; margin-top:8px;'>※ 本表由採檢單位上傳至癌症篩檢與追蹤管理資訊整合系統。</p>"
        }
      ]
    }
  ],
  "questionErrorLocation": "bottom",
  "checkErrorsMode": "onComplete",
  "pagePrevText": "上一頁",
  "pageNextText": "下一頁",
  "completeText": "提交"
}