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[null,"結核検査およびチェックリスト"]
[]
[null,"氏　名                       　　　    様"]
[]
[null,null,"検  査","　　結　果",null,null,null,"　施行日　　　","　年　　　月　　　日"]
[null,null,"□胸部X-P","□異常なし"]
[null,null,null,"□異常あり",null,"□空洞","□粒状","□胸水","□その他（　　　　　　　　）"]
[null,null,null,"□疑わしい"]
[null,null,null,"□過去に罹患した形跡あり"]
[]
[]
[]
[null,null,"身体状態"]
[]
[null,null,"・体重減少(6ヶ月前から）","□なし"]
[null,null,null,"□ある","（　　　ｋｇから　　　　ｋｇに）"]
[]
[null,null,"・2週間以上咳が続いている","□なし"]
[null,null,null,"□ある","（　　月　　日頃から）"]
[]
[null,null,"・微熱が続いている","□なし",null,null,"・抗生物質の使用",null,"□なし","□ある（　　　　　　　　　　　）"]
[null,null,null,"□ある","（　　月　　日頃から）",null,"・抗生物質の有効性",null,"□なし","□あり"]
[]
[null,null,"・痰が出る","□なし"]
[null,null,null,"□ある","（　　月　　日頃から）"]
[]
[null,null,"・倦怠感","□なし"]
[null,null,null,"□ある","（　　月　　日頃から）"]
[]
[null,null,"・結核の既往","□なし"]
[null,null,null,"□ある","抗結核薬の服用（　　年　　月頃から　　　年　　　月まで）"]
[{"$nulls":4},"□治癒　　□放置"]
[]
[null,null,"・結核罹患者との接触","□なし"]
[null,null,null,"□あり","（　　年　　月　頃）",null,"　　　　罹患者との関係（　　　　　　　）"]
[{"$nulls":6},"(2年以内の接触であればQFT検査実施)"]
[null,null,"・接触者検診","□なし"]
[null,null,null,"□あり","保健所または医療機関で喀痰塗沫検査連続3回陰性になった時期（　　年　　月）"]
[]
[{"$nulls":4},"ハイリスク接触者で",null,"□ない"]
[{"$nulls":6},"□ある","免疫不全疾患・管理不良の糖尿病者（HbA1c9.0)"]
[{"$nulls":7},"抗がん剤服用中・ステロイド剤服用中"]
[{"$nulls":7},"人工透析中・臓器移植を受けている・珪肺"]
[{"$nulls":7},"血友病・肝硬変"]
[]
[]
[]
[]
[]
[null,null,"【診断結果】"]
[null,null,"※集団感染防止の観点から、施設（入所・通所）利用の要否を医学的見地から、ご診断願います。"]
[]
[{"$nulls":8},"　　　　　　　年　　　月　　　日"]
[null,null,"　　　□結核感染なし"]
[null,null,"　　　□結核感染の疑いがあるため、施設利用の制限を要する。"]
[]
[]
[]
[{"$nulls":7},"医師氏名："]

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