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