{"id":8862,"date":"2026-01-28T00:00:13","date_gmt":"2026-01-27T15:00:13","guid":{"rendered":"https:\/\/mrclinic.tokyo\/cn\/?page_id=8862"},"modified":"2026-04-02T16:14:53","modified_gmt":"2026-04-02T07:14:53","slug":"regenerative-treatment-questionnaire","status":"publish","type":"page","link":"https:\/\/mrclinic.tokyo\/cn\/regenerative-treatment-questionnaire\/","title":{"rendered":"\u518d\u751f\u533b\u5b66\u95ee\u8bca\u8868"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"8862\" class=\"elementor elementor-8862\">\n\t\t\t\t<div class=\"elementor-element elementor-element-79862f8f e-flex e-con-boxed e-con e-parent\" data-id=\"79862f8f\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-3f53b103 e-con-full e-flex e-con e-child\" data-id=\"3f53b103\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-50008015 elementor-widget elementor-widget-spacer\" data-id=\"50008015\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-43848767 elementor-widget elementor-widget-heading\" data-id=\"43848767\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">\u518d\u751f\u533b\u5b66\u95ee\u8bca\u8868<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element 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action=\"\/cn\/wp-json\/wp\/v2\/pages\/8862#wpcf7-f8861-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"\u7559\u8a00\u8868\u5355\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"8861\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"zh_CN\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f8861-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"mrc-contact-form\">\n\t<p><span class=\"part required\">\u8f93\u5165\u65e5\u671f <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-entry-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date lengthdate\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"your-entry-date\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u60a3\u8005\u4fe1\u606f<\/span><br \/>\n<span class=\"required\">\u59d3\u540d<\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span><\/span><br \/>\n<span class=\"required\">\u6027\u5225 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-gender\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-gender\" value=\"\u7537\u6027\" \/><span class=\"wpcf7-list-item-label\">\u7537\u6027<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-gender\" value=\"\u5973\u6027\" \/><span class=\"wpcf7-list-item-label\">\u5973\u6027<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"required\">\u51fa\u751f\u65e5\u671f <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-birthday\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"your-birthday\" \/><\/span><\/span><span> (<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-age\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-age\" \/><\/span><\/span><span> \u5c81)<\/span><br \/>\n<span class=\"required\">\u56fd\u7c4d <\/span><span> <span class=\"wpcf7-form-control-wrap\" data-name=\"your-nationality\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text 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class=\"part\">\u60a8\u5e0c\u671b\u6539\u5584\u7684\u5173\u6ce8\u95ee\u9898<\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"want-improve\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u75bc\u75db\" \/><span class=\"wpcf7-list-item-label\">\u75bc\u75db<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u7cd6\u5c3f\u75c5\" \/><span class=\"wpcf7-list-item-label\">\u7cd6\u5c3f\u75c5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u809d\u529f\u80fd\" \/><span class=\"wpcf7-list-item-label\">\u809d\u529f\u80fd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u80be\u529f\u80fd\" \/><span class=\"wpcf7-list-item-label\">\u80be\u529f\u80fd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u6027\u529f\u80fd\" \/><span class=\"wpcf7-list-item-label\">\u6027\u529f\u80fd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u7f8e\u5bb9\uff08\u76ae\u80a4\u30fb\u751f\u53d1\uff09\" \/><span class=\"wpcf7-list-item-label\">\u7f8e\u5bb9\uff08\u76ae\u80a4\u30fb\u751f\u53d1\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u8ba4\u77e5\u529f\u80fd\u4e0b\u964d\u9884\u9632\" \/><span class=\"wpcf7-list-item-label\">\u8ba4\u77e5\u529f\u80fd\u4e0b\u964d\u9884\u9632<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"want-improve-other\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"want-improve-other[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"want-improve-other-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"want-improve-other-text\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u5728\u5176\u4ed6\u533b\u9662\u63a5\u53d7\u7684\u6cbb\u7597<\/span><br \/>\n<span class=\"section required\">\u624b\u672f\u5386\u53f2<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-surgery\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-surgery\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-surgery\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u63a5\u53d7\u624b\u672f\u7684\u5e74\u4efd <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-surgery-year\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"treatment-another-hospital-surgery-year\" \/><\/span><\/span><span>\u624b\u672f\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-surgery-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-surgery-location\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">\u6297\u8870\u8001 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-antiaging\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-antiaging-items\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u900f\u660e\u8d28\u9178\u6ce8\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u900f\u660e\u8d28\u9178\u6ce8\u5c04<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u8089\u6bd2\u7d20\u6ce8\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u8089\u6bd2\u7d20\u6ce8\u5c04<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u679c\u9178\u6362\u80a4\" \/><span class=\"wpcf7-list-item-label\">\u679c\u9178\u6362\u80a4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u7ebf\u96d5\uff08\u7ebf\u63d0\u5347\uff09\" \/><span class=\"wpcf7-list-item-label\">\u7ebf\u96d5\uff08\u7ebf\u63d0\u5347\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u6fc0\u5149\u6cbb\u7597\" \/><span class=\"wpcf7-list-item-label\">\u6fc0\u5149\u6cbb\u7597<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u62bd\u8102\" \/><span class=\"wpcf7-list-item-label\">\u62bd\u8102<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">\u518d\u751f\u533b\u5b66 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u60a8\u4ec0\u4e48\u65f6\u5019\u63a5\u53d7\u4e86\u6cbb\u7597\uff1f<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-when\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-when\" \/><\/span><\/span><br \/>\n<span>\u6cbb\u7597\u65b9\u5f0f <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-treatment\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"PRP\" \/><span class=\"wpcf7-list-item-label\">PRP<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"APS\" \/><span class=\"wpcf7-list-item-label\">APS<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"FGF\" \/><span class=\"wpcf7-list-item-label\">FGF<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"ACRS\" \/><span class=\"wpcf7-list-item-label\">ACRS<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"\u4e0a\u6e05\u6db2\u6cbb\u7597\" \/><span class=\"wpcf7-list-item-label\">\u4e0a\u6e05\u6db2\u6cbb\u7597<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"\u5e72\u7ec6\u80de\u6cbb\u7597\" \/><span class=\"wpcf7-list-item-label\">\u5e72\u7ec6\u80de\u6cbb\u7597<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u5728\u54ea\u91cc\u63a5\u53d7\u4e86\u6cbb\u7597\uff1f<\/span><br \/>\n<span>\u56fd\u5bb6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-country\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"treatment-another-hospital-regenerative-country\"><option value=\"\">&#8212;\u8bf7\u9009\u62e9&#8212;<\/option><option value=\"\u8fea\u62dc (Dubai\u30fbUAE)\">\u8fea\u62dc (Dubai\u30fbUAE)<\/option><option value=\"\u97e9\u56fd (South Korea)\">\u97e9\u56fd (South Korea)<\/option><option value=\"\u9a6c\u6765\u897f\u4e9a (Malaysia)\">\u9a6c\u6765\u897f\u4e9a (Malaysia)<\/option><option value=\"\u58a8\u897f\u54e5 (Mexico)\">\u58a8\u897f\u54e5 (Mexico)<\/option><option value=\"\u6cf0\u56fd (Thailand)\">\u6cf0\u56fd (Thailand)<\/option><option value=\"\u4e4c\u514b\u5170 (Ukraine)\">\u4e4c\u514b\u5170 (Ukraine)<\/option><option value=\"\u5176\u4ed6\">\u5176\u4ed6<\/option><\/select><\/span><\/span><span> \u5176\u4ed6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-country-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-country-other\" \/><\/span><\/span><br \/>\n<span>\u5730\u533a <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-area\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-area\" \/><\/span><\/span><span> \u533b\u9662\u540d\u79f0 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-clinic\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-clinic\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span>\u8bf7\u8be6\u7ec6\u586b\u5199\u5e72\u7ec6\u80de\u6cbb\u7597\u4fe1\u606f\uff08\u5982\u679c\u9002\u7528\uff09<\/span><br \/>\n<span>\u7ed9\u836f\u65b9\u6cd5 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-method\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-stemcell-method[]\" value=\"\u9759\u8109\u6ce8\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u9759\u8109\u6ce8\u5c04<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-stemcell-method[]\" value=\"\u5c40\u90e8\u6ce8\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u5c40\u90e8\u6ce8\u5c04<\/span><\/label><\/span><\/span><\/span><\/span><span>\u6ce8\u5c04\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-injectionsite\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-stemcell-injectionsite\" \/><\/span><\/span><br \/>\n<span>\u7ed9\u836f\u6b21\u6570 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-administrations-count\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"treatment-another-hospital-regenerative-stemcell-administrations-count\" \/><\/span><\/span><span>\u6b21\u6570<\/span><br \/>\n<span>\u7ed9\u836f\u7684\u7ec6\u80de\u6570\u91cf <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-cells-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-another-hospital-regenerative-stemcell-cells-number\" \/><\/span><\/span><br \/>\n<span>\u52b9\u679c <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-regenerative-stemcell-effectiveness\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"treatment-another-hospital-regenerative-stemcell-effectiveness\"><option value=\"\">&#8212;\u8bf7\u9009\u62e9&#8212;<\/option><option value=\"\u6539\u5584\">\u6539\u5584<\/option><option value=\"\u6076\u5316\">\u6076\u5316<\/option><option value=\"\u65e0\u53d8\u5316\">\u65e0\u53d8\u5316<\/option><\/select><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"required\">\u75bc\u75db\u6cbb\u7597 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-pain\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-pain-detail\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"\u810a\u690e\u6309\u6469\" \/><span class=\"wpcf7-list-item-label\">\u810a\u690e\u6309\u6469<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"\u9488\u7078\" \/><span class=\"wpcf7-list-item-label\">\u9488\u7078<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"\u6309\u6469\" \/><span class=\"wpcf7-list-item-label\">\u6309\u6469<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"\u6ce8\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u6ce8\u5c04<\/span><\/label><\/span><\/span><\/span><\/span><span class=\"heading\">\u5176\u4ed6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-at-another-hospital-pain-detail-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"treatment-at-another-hospital-pain-detail-other\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"required\">\u6765\u81ea\u5176\u4ed6\u533b\u9662\u7684\u6570\u636e <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"data-from-other-hospitals\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals\" value=\"\u6709\" \/><span class=\"wpcf7-list-item-label\">\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"data-from-other-hospitals-items\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u8bca\u65ad\u4e66\" \/><span class=\"wpcf7-list-item-label\">\u8bca\u65ad\u4e66<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u6cbb\u7597\u7ecf\u8fc7\u8bb0\u5f55\" \/><span class=\"wpcf7-list-item-label\">\u6cbb\u7597\u7ecf\u8fc7\u8bb0\u5f55<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u8840\u6db2\u68c0\u67e5\u7ed3\u679c\" \/><span class=\"wpcf7-list-item-label\">\u8840\u6db2\u68c0\u67e5\u7ed3\u679c<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"X\u5149\" \/><span class=\"wpcf7-list-item-label\">X\u5149<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"CT\u626b\u63cf\" \/><span class=\"wpcf7-list-item-label\">CT\u626b\u63cf<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"MRI\" \/><span class=\"wpcf7-list-item-label\">MRI<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"PET\u626b\u63cf\" \/><span class=\"wpcf7-list-item-label\">PET\u626b\u63cf<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u624b\u672f\u8bb0\u5f55\" \/><span class=\"wpcf7-list-item-label\">\u624b\u672f\u8bb0\u5f55<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u653e\u5c04\u6cbb\u7597\u8bb0\u5f55\" \/><span class=\"wpcf7-list-item-label\">\u653e\u5c04\u6cbb\u7597\u8bb0\u5f55<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u5316\u7597\u8bb0\u5f55\" \/><span class=\"wpcf7-list-item-label\">\u5316\u7597\u8bb0\u5f55<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u5982\u679c\u60a8\u6709\u6765\u81ea\u5176\u4ed6\u533b\u9662\u7684\u533b\u7597\u8bb0\u5f55\uff0c\u8bf7\u4ece\u8fd9\u91cc\u4e0a\u4f20\u3002<br \/>\n(\u56fe\u7247\u6587\u4ef6\u30fbPDF\u683c\u5f0f\uff0c10MB\u4ee5\u5185)<\/span><br \/>\n<span>\u9644\u4ef6\u6587\u4ef6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"data-from-other-hospitals-uploadfile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpeg,.jpg,.png,.gif,.bmp,.pdf\" aria-invalid=\"false\" type=\"file\" name=\"data-from-other-hospitals-uploadfile\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"heading\">\u5176\u4ed6 <\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"treatment-another-hospital-other\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"treatment-another-hospital-other\"><\/textarea><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">\u6cbb\u7597\u4e2d\u7684\u75c5\u72b6\/\u6162\u6027\u75c5<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"under-treatment\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u9ad8\u8840\u538b\uff08\u9ad8\u8840\u538b\u75c7\uff09\" \/><span class=\"wpcf7-list-item-label\">\u9ad8\u8840\u538b\uff08\u9ad8\u8840\u538b\u75c7\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u7cd6\u5c3f\u75c5\" \/><span class=\"wpcf7-list-item-label\">\u7cd6\u5c3f\u75c5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u809d\u810f\u75be\u75c5\" \/><span class=\"wpcf7-list-item-label\">\u809d\u810f\u75be\u75c5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u80be\u810f\u75be\u75c5\" \/><span class=\"wpcf7-list-item-label\">\u80be\u810f\u75be\u75c5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u5fc3\u810f\u75c5\" \/><span class=\"wpcf7-list-item-label\">\u5fc3\u810f\u75c5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u8111\u51fa\u8840\u30fb\u8111\u6897\u585e\" \/><span class=\"wpcf7-list-item-label\">\u8111\u51fa\u8840\u30fb\u8111\u6897\u585e<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u54ee\u5598\u30fbCOPD\" \/><span class=\"wpcf7-list-item-label\">\u54ee\u5598\u30fbCOPD<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u514d\u75ab\u7cfb\u7edf\u75be\u75c5\" \/><span class=\"wpcf7-list-item-label\">\u514d\u75ab\u7cfb\u7edf\u75be\u75c5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u6076\u6027\u80bf\u7624\" \/><span class=\"wpcf7-list-item-label\">\u6076\u6027\u80bf\u7624<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u7cbe\u795e\u75be\u75c5\" \/><span class=\"wpcf7-list-item-label\">\u7cbe\u795e\u75be\u75c5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u4e0d\u5b55\u75c7\" \/><span class=\"wpcf7-list-item-label\">\u4e0d\u5b55\u75c7<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"required\">\u4f20\u67d3\u75c5\u6cbb\u7597 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"under-treatment-infectious\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"under-treatment-infectious\" value=\"\u6709\" \/><span class=\"wpcf7-list-item-label\">\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"under-treatment-infectious\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u5982\u679c\u6709\uff0c\u60a8\u6b63\u5728\u6cbb\u7597\u4ee5\u4e0b\u54ea\u4e9b\u4f20\u67d3\u75c5\uff1f\uff08\u8bf7\u52fe\u9009\u6240\u6709\u9002\u7528\u9879\uff09<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"under-treatment-infectious-items\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"\u809d\u708e(A)\" \/><span class=\"wpcf7-list-item-label\">\u809d\u708e(A)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"\u809d\u708e(B)\" \/><span class=\"wpcf7-list-item-label\">\u809d\u708e(B)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"\u809d\u708e(C)\" \/><span class=\"wpcf7-list-item-label\">\u809d\u708e(C)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"\u7ed3\u6838\" \/><span class=\"wpcf7-list-item-label\">\u7ed3\u6838<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"\u6885\u6bd2\" \/><span class=\"wpcf7-list-item-label\">\u6885\u6bd2<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"HIV\/AIDS\" \/><span class=\"wpcf7-list-item-label\">HIV\/AIDS<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"under-treatment-infectious-items[]\" value=\"HTLV-1\" \/><span class=\"wpcf7-list-item-label\">HTLV-1<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section\">\u5f53\u524d\u670d\u7528\u7684\u836f\u7269\u30fb\u4fdd\u5065\u836f\u54c1<\/span><br \/>\n\u8bf7\u5217\u51fa\u60a8\u6b63\u5728\u670d\u7528\u7684\u836f\u7269\u540d\u79f0\u548c\u5242\u91cf\uff08\u6709\u6548\u6210\u5206\u91cf\uff0c\u4f8b\u5982\uff1amg\uff09<br \/>\n<span class=\"required\">\u6297\u8840\u5c0f\u677f\u836f\u7269 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-supplements-blood-thinners\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinners\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinners\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-supplements-blood-thinners-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-supplements-blood-thinners-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">\u8840\u6db2\u7a00\u91ca\u8865\u5145\u5242 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-supplements-blood-thinning-supplements\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinning-supplements\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinning-supplements\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-supplements-blood-thinning-supplements-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-supplements-blood-thinning-supplements-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">\u9ad8\u8840\u538b\u836f\u7269 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-hypertension-medications\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-hypertension-medications\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-hypertension-medications\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-hypertension-medications-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-hypertension-medications-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">\u7cd6\u5c3f\u75c5\u836f\u7269 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-diabetes-medications\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-diabetes-medications\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-diabetes-medications\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-diabetes-medications-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-diabetes-medications-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">\u5973\u6027\u6fc0\u7d20\u6cbb\u7597\u836f\u7269 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-female-hormone-therapy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-female-hormone-therapy\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-female-hormone-therapy\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-female-hormone-therapy-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-female-hormone-therapy-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">\u7cbe\u795e\u836f\u7269 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-psychiatric-medications\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"current-medications-psychiatric-medications\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-psychiatric-medications\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-psychiatric-medications-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-psychiatric-medications-text\" \/><\/span><\/span><br \/>\n<span>\u5176\u4ed6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"current-medications-others-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"current-medications-others-text\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u793e\u4f1a\u53f2<\/span><br \/>\n<span class=\"section required\">\u9152\u7cbe <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-alcohol\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"social-history-alcohol\" value=\"\u4e0d\u559d\" \/><span class=\"wpcf7-list-item-label\">\u4e0d\u559d<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"social-history-alcohol\" value=\"\u559d\" \/><span class=\"wpcf7-list-item-label\">\u559d<\/span><\/label><\/span><\/span><\/span><\/span><span> ( <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-alcohol-amount\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"social-history-alcohol-amount\"><option value=\"\">&#8212;\u8bf7\u9009\u62e9&#8212;<\/option><option value=\"1\u676f\u65e5\u672c\u9152\">1\u676f\u65e5\u672c\u9152<\/option><option value=\"1\u5927\u74f6\u5564\u9152\">1\u5927\u74f6\u5564\u9152<\/option><option value=\"2\/3\u676f\u70e7\u9152\/\u84b8\u998f\u9152\uff08\u767d\u9152\uff09\">2\/3\u676f\u70e7\u9152\/\u84b8\u998f\u9152\uff08\u767d\u9152\uff09<\/option><option value=\"1\u676f\u53cc\u4efd\u5a01\u58eb\u5fcc\">1\u676f\u53cc\u4efd\u5a01\u58eb\u5fcc<\/option><option value=\"1\/3\u74f6\u8461\u8404\u9152\">1\/3\u74f6\u8461\u8404\u9152<\/option><option value=\"\u996e\u7528\u8d85\u8fc7\u6b64\u91cf\">\u996e\u7528\u8d85\u8fc7\u6b64\u91cf<\/option><\/select><\/span><\/span><span> ) <\/span><br \/>\n<span class=\"section required\">\u5438\u70df <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-tobacco\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"social-history-tobacco\" value=\"\u4e0d\u5438\" \/><span class=\"wpcf7-list-item-label\">\u4e0d\u5438<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"social-history-tobacco\" value=\"\u5438\" \/><span class=\"wpcf7-list-item-label\">\u5438<\/span><\/label><\/span><\/span><\/span><\/span><span> ( \u6bcf\u5929 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"social-history-tobacco-amount\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"social-history-tobacco-amount\" \/><\/span><\/span><span> \u652f\u9999\u70df ) <\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u75c5\u53f2<\/span><br \/>\n<span class=\"section\">\u8fc7\u654f\u53f2<\/span><br \/>\n<span class=\"subsection required\">\u98df\u7269\u8fc7\u654f <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-food\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u7315\u7334\u6843\" \/><span class=\"wpcf7-list-item-label\">\u7315\u7334\u6843<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u9999\u8549\" \/><span class=\"wpcf7-list-item-label\">\u9999\u8549<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u9cc4\u68a8\" \/><span class=\"wpcf7-list-item-label\">\u9cc4\u68a8<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u6728\u74dc\" \/><span class=\"wpcf7-list-item-label\">\u6728\u74dc<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u8292\u679c\" \/><span class=\"wpcf7-list-item-label\">\u8292\u679c<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u751c\u74dc\" \/><span class=\"wpcf7-list-item-label\">\u751c\u74dc<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u65e0\u82b1\u679c\" \/><span class=\"wpcf7-list-item-label\">\u65e0\u82b1\u679c<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u6a31\u6843\" \/><span class=\"wpcf7-list-item-label\">\u6a31\u6843<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u9e21\u86cb\" \/><span class=\"wpcf7-list-item-label\">\u9e21\u86cb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u5927\u8c46\" \/><span class=\"wpcf7-list-item-label\">\u5927\u8c46<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u5c0f\u9ea6\" \/><span class=\"wpcf7-list-item-label\">\u5c0f\u9ea6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u82b1\u751f\" \/><span class=\"wpcf7-list-item-label\">\u82b1\u751f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u9752\u80cc\u9c7c\uff08\u4f8b\u5982\uff1a\u9cad\u9c7c\u3001\u6c99\u4e01\u9c7c\uff09\" \/><span class=\"wpcf7-list-item-label\">\u9752\u80cc\u9c7c\uff08\u4f8b\u5982\uff1a\u9cad\u9c7c\u3001\u6c99\u4e01\u9c7c\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u5982\u679c\u60a8\u9009\u62e9\u4e86\u201c\u5176\u4ed6\u201d\uff0c\u8bf7\u5177\u4f53\u586b\u5199\u98df\u7269\u540d\u79f0\u3002<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-food-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergies-food-other\" \/><\/span><\/span><br \/>\n<span>\u8fc7\u654f\u53cd\u5e94\u7684\u4e25\u91cd\u7a0b\u5ea6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-food-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"\u8f7b\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u8f7b\u5ea6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"\u4e2d\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u4e2d\u5ea6<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"\u91cd\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u91cd\u5ea6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u836f\u7269\u8fc7\u654f <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-medication\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u963f\u53f8\u5339\u6797\uff08\u4f8b\u5982\uff1aBufferin\uff09\" \/><span class=\"wpcf7-list-item-label\">\u963f\u53f8\u5339\u6797\uff08\u4f8b\u5982\uff1aBufferin\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u5e03\u6d1b\u82ac\uff08\u4f8b\u5982\uff1aBrufen\u3001Eve\uff09\" \/><span class=\"wpcf7-list-item-label\">\u5e03\u6d1b\u82ac\uff08\u4f8b\u5982\uff1aBrufen\u3001Eve\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u6d1b\u7d22\u6d1b\u82ac\uff08\u4f8b\u5982\uff1aLoxonin\uff09\" \/><span class=\"wpcf7-list-item-label\">\u6d1b\u7d22\u6d1b\u82ac\uff08\u4f8b\u5982\uff1aLoxonin\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u9ebb\u9189\u836f\uff08\u4f8b\u5982\uff1a\u5229\u591a\u5361\u56e0\uff09\" \/><span class=\"wpcf7-list-item-label\">\u9ebb\u9189\u836f\uff08\u4f8b\u5982\uff1a\u5229\u591a\u5361\u56e0\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u5982\u679c\u60a8\u9009\u62e9\u4e86\u201c\u5176\u4ed6\u201d\uff0c\u8bf7\u5177\u4f53\u586b\u5199\u836f\u54c1\u540d\u79f0\u3002<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-medication-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergies-medication-other\" \/><\/span><\/span><br \/>\n<span>\u8fc7\u654f\u53cd\u5e94\u7684\u4e25\u91cd\u7a0b\u5ea6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-medication-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"\u8f7b\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u8f7b\u5ea6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"\u4e2d\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u4e2d\u5ea6<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"\u91cd\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u91cd\u5ea6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u6297\u751f\u7d20\/\u6297\u771f\u83cc\u836f <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-antibiotics\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u9752\u9709\u7d20\u7c7b\" \/><span class=\"wpcf7-list-item-label\">\u9752\u9709\u7d20\u7c7b<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u5934\u5b62\u83cc\u7d20\u7c7b\uff08\u4f8b\u5982\uff1a\u5934\u5b62\u544b\u8f9b\uff09\" \/><span class=\"wpcf7-list-item-label\">\u5934\u5b62\u83cc\u7d20\u7c7b\uff08\u4f8b\u5982\uff1a\u5934\u5b62\u544b\u8f9b\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u94fe\u9709\u7d20\" \/><span class=\"wpcf7-list-item-label\">\u94fe\u9709\u7d20<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u963f\u7c73\u5361\u661f\" \/><span class=\"wpcf7-list-item-label\">\u963f\u7c73\u5361\u661f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u6c28\u57fa\u7cd6\u82f7\u7c7b\uff08\u4e0d\u5305\u62ec\u94fe\u9709\u7d20\u3001\u963f\u7c73\u5361\u661f\uff09\" \/><span class=\"wpcf7-list-item-label\">\u6c28\u57fa\u7cd6\u82f7\u7c7b\uff08\u4e0d\u5305\u62ec\u94fe\u9709\u7d20\u3001\u963f\u7c73\u5361\u661f\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u4e24\u6027\u9709\u7d20B\" \/><span class=\"wpcf7-list-item-label\">\u4e24\u6027\u9709\u7d20B<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u5982\u679c\u60a8\u9009\u62e9\u4e86\u201c\u5176\u4ed6\u201d\uff0c\u8bf7\u5177\u4f53\u586b\u5199\u836f\u54c1\u540d\u79f0\u3002<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-antibiotics-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergies-antibiotics-other\" \/><\/span><\/span><br \/>\n<span>\u8fc7\u654f\u53cd\u5e94\u7684\u4e25\u91cd\u7a0b\u5ea6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-antibiotics-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"\u8f7b\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u8f7b\u5ea6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"\u4e2d\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u4e2d\u5ea6<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"\u91cd\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u91cd\u5ea6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u5176\u4ed6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-other\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"\u4e73\u80f6\" \/><span class=\"wpcf7-list-item-label\">\u4e73\u80f6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"\u9152\u7cbe\" \/><span class=\"wpcf7-list-item-label\">\u9152\u7cbe<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"\u7898\" \/><span class=\"wpcf7-list-item-label\">\u7898<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u8fc7\u654f\u53cd\u5e94\u7684\u4e25\u91cd\u7a0b\u5ea6<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-other-severity\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"\u8f7b\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u8f7b\u5ea6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"\u4e2d\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u4e2d\u5ea6<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"\u91cd\u5ea6\" \/><span class=\"wpcf7-list-item-label\">\u91cd\u5ea6<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">\u60a8\u662f\u5426\u66fe\u56e0\u9ebb\u9189\uff08\u5982\u7259\u79d1\u9ebb\u9189\u5229\u591a\u5361\u56e0\u6216\u80c3\u955c\uff09\u800c\u611f\u5230\u4e0d\u9002\uff1f <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"anesthesia\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"anesthesia\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"anesthesia\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u60a8\u662f\u5426\u6000\u5b55\u6216\u6709\u6000\u5b55\u98ce\u9669\uff08\u8fc7\u53bb3\u4e2a\u6708\u5185\u6d41\u4ea7\u6216\u5815\u80ce\uff09\uff1f <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"pregnancy\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"pregnancy\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pregnancy\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u7d27\u6025\u8054\u7cfb\u4eba<\/span><br \/>\n<span>\u59d3\u540d<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-ec-name\" \/><\/span><br \/>\n<span>\u7535\u8bdd\u53f7\u7801<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-phone-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-ec-phone-number\" \/><\/span><br \/>\n<span>\u7535\u5b50\u90ae\u4ef6\u5730\u5740<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-ec-email\" \/><\/span><br \/>\n<span>\u4e0e\u672c\u4eba\u5173\u7cfb<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-ec-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-ec-relationship\" \/><\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u5176\u4ed6\u4fe1\u606f <\/span><span>\u8bf7\u586b\u5199\u4efb\u4f55\u53ef\u80fd\u4e0e\u60a8\u6574\u4f53\u5065\u5eb7\u72b6\u51b5\u76f8\u5173\u7684\u9644\u52a0\u4fe1\u606f<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"additional-notes\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"additional-notes\"><\/textarea><\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u5bf9\u672c\u9662\u7684\u671f\u671b\u30fb\u63a8\u8350\u6765\u6e90<\/span><br \/>\n<span class=\"section required\">\u8bf7\u9009\u62e9\u60a8\u7684\u54a8\u8be2\u76ee\u7684<\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"purpose-of-your-inquiry\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"\u60f3\u7acb\u5373\u6cbb\u7597\" \/><span class=\"wpcf7-list-item-label\">\u60f3\u7acb\u5373\u6cbb\u7597<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"\u60f3\u9884\u7ea6\u6765\u9662\" \/><span class=\"wpcf7-list-item-label\">\u60f3\u9884\u7ea6\u6765\u9662<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"\u60f3\u4e86\u89e3\u8bca\u7597\u5185\u5bb9\u30fb\u6cbb\u7597\u65b9\u6cd5\" \/><span class=\"wpcf7-list-item-label\">\u60f3\u4e86\u89e3\u8bca\u7597\u5185\u5bb9\u30fb\u6cbb\u7597\u65b9\u6cd5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"\u60f3\u4e86\u89e3\u8d39\u7528\u30fb\u652f\u4ed8\u65b9\u5f0f\" \/><span class=\"wpcf7-list-item-label\">\u60f3\u4e86\u89e3\u8d39\u7528\u30fb\u652f\u4ed8\u65b9\u5f0f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"\u60f3\u4e86\u89e3\u5176\u4ed6\u4e8b\u9879\" \/><span class=\"wpcf7-list-item-label\">\u60f3\u4e86\u89e3\u5176\u4ed6\u4e8b\u9879<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">\u60a8\u662f\u5982\u4f55\u5f97\u77e5\u672c\u9662\u7684\uff1f<\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"how-about-our-clinic\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u670b\u53cb\u4ecb\u7ecd\" \/><span class=\"wpcf7-list-item-label\">\u670b\u53cb\u4ecb\u7ecd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u4ee3\u7406\u5546\u4ecb\u7ecd\" \/><span class=\"wpcf7-list-item-label\">\u4ee3\u7406\u5546\u4ecb\u7ecd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u53c2\u52a0\u4e86\u8bb2\u5ea7\" \/><span class=\"wpcf7-list-item-label\">\u53c2\u52a0\u4e86\u8bb2\u5ea7<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u67e5\u770b\u4e86\u7f51\u7ad9\" \/><span class=\"wpcf7-list-item-label\">\u67e5\u770b\u4e86\u7f51\u7ad9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Instagram\" \/><span class=\"wpcf7-list-item-label\">Instagram<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"Facebook\" \/><span class=\"wpcf7-list-item-label\">Facebook<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u5fae\u4fe1\" \/><span class=\"wpcf7-list-item-label\">\u5fae\u4fe1<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u5982\u679c\u9009\u62e9\u201c\u5176\u4ed6\u201d\uff0c\u8bf7\u586b\u5199\u60a8\u5f97\u77e5\u672c\u9662\u7684\u9014\u5f84<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"how-about-our-clinic-other\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"how-about-our-clinic-other\" \/><\/span><br \/>\n\u611f\u8c22\u60a8\u7684\u914d\u5408\u4e0e\u652f\u6301\uff0c\u8877\u5fc3\u611f\u8c22\uff01\n\t<\/p>\n\t<p><div class=\"cf7-cf-turnstile\" style=\"margin-top: 0px; margin-bottom: -15px;\"> <div id=\"cf-turnstile-cf7-42067395\" class=\"cf-turnstile\" data-sitekey=\"0x4AAAAAABuDRJ0AuuoVnJNF\" data-theme=\"auto\" data-language=\"auto\" data-size=\"normal\" data-retry=\"auto\" data-retry-interval=\"1000\" data-refresh-expired=\"auto\" data-refresh-timeout=\"auto\" data-action=\"contact-form-7\" data-callback=\"turnstileCF7Callback\" data-appearance=\"always\"><\/div> <script>document.addEventListener(\"DOMContentLoaded\", function() { setTimeout(function(){ var e=document.getElementById(\"cf-turnstile-cf7-42067395\"); if(e&&!e.innerHTML.trim()){turnstile.render(e, {sitekey:\"0x4AAAAAABuDRJ0AuuoVnJNF\"});} }, 200); });<\/script> <br class=\"cf-turnstile-br cf-turnstile-br-cf7-42067395\"> <style>#cf-turnstile-cf7-42067395 { margin-left: -15px; }<\/style> <script>document.addEventListener(\"DOMContentLoaded\",function(){document.querySelectorAll('.wpcf7-form').forEach(function(e){e.addEventListener('submit',function(){if(document.getElementById('cf-turnstile-cf7-42067395')){setTimeout(function(){turnstile.reset('#cf-turnstile-cf7-42067395');},1000)}})})});<\/script> <\/div><br\/><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"\u53d1\u9001\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-c0e7c33 e-flex e-con-boxed e-con e-parent\" data-id=\"c0e7c33\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;jet_parallax_layout_list&quot;:[]}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-14acf0c1 elementor-widget elementor-widget-spacer\" data-id=\"14acf0c1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>\u518d\u751f\u533b\u5b66\u95ee\u8bca\u8868 \u5bf9\u4e8e\u6709\u610f\u4e86\u89e3\u518d\u751f\u533b\u5b66\u7684\u60a3\u8005\uff0c\u8bf7\u5728\u54a8\u8be2\u524d\u586b\u5199\u5e76\u63d0\u4ea4\u6b64\u95ee\u5377\u3002\u901a\u8fc7\u63d0\u524d\u5171\u4eab\u60a8\u7684\u60c5\u51b5\uff0c\u53ef\u4ee5\u5e2e\u52a9\u7f29\u77ed\u54a8\u8be2 [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-8862","page","type-page","status-publish","hentry","no-thumb"],"_links":{"self":[{"href":"https:\/\/mrclinic.tokyo\/cn\/wp-json\/wp\/v2\/pages\/8862","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mrclinic.tokyo\/cn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mrclinic.tokyo\/cn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mrclinic.tokyo\/cn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mrclinic.tokyo\/cn\/wp-json\/wp\/v2\/comments?post=8862"}],"version-history":[{"count":15,"href":"https:\/\/mrclinic.tokyo\/cn\/wp-json\/wp\/v2\/pages\/8862\/revisions"}],"predecessor-version":[{"id":9438,"href":"https:\/\/mrclinic.tokyo\/cn\/wp-json\/wp\/v2\/pages\/8862\/revisions\/9438"}],"wp:attachment":[{"href":"https:\/\/mrclinic.tokyo\/cn\/wp-json\/wp\/v2\/media?parent=8862"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}