{"id":8872,"date":"2026-01-29T00:00:41","date_gmt":"2026-01-28T15:00:41","guid":{"rendered":"https:\/\/mrclinic.tokyo\/cn\/?page_id=8872"},"modified":"2026-04-02T15:51:07","modified_gmt":"2026-04-02T06:51:07","slug":"cancer-treatment-questionnaire","status":"publish","type":"page","link":"https:\/\/mrclinic.tokyo\/cn\/cancer-treatment-questionnaire\/","title":{"rendered":"\u764c\u75c7\u6cbb\u7597\u95ee\u8bca\u8868"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"8872\" class=\"elementor elementor-8872\">\n\t\t\t\t<div class=\"elementor-element elementor-element-384240dc e-flex e-con-boxed e-con e-parent\" data-id=\"384240dc\" 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-656d5de9 e-con-full e-flex e-con e-child\" data-id=\"656d5de9\" 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-2eb8cd60 elementor-widget elementor-widget-spacer\" data-id=\"2eb8cd60\" 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-573199b1 elementor-widget elementor-widget-heading\" data-id=\"573199b1\" 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\">\u764c\u75c7\u6cbb\u7597\u95ee\u8bca\u8868<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-342e5d0f elementor-widget elementor-widget-text-editor\" data-id=\"342e5d0f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>\u5982\u679c\u60a8\u5e0c\u671b\u63a5\u53d7\u764c\u75c7\u6cbb\u7597\uff0c\u8bf7\u5728\u54a8\u8be2\u524d\u586b\u5199\u5e76\u63d0\u4ea4\u95ee\u5377\u3002\u63d0\u524d\u5206\u4eab\u60a8\u7684\u4fe1\u606f\u5c06\u6709\u52a9\u4e8e\u7f29\u77ed\u54a8\u8be2\u65f6\u95f4\uff0c\u5e76\u4e3a\u63d0\u4f9b\u66f4\u6df1\u5165\u3001\u9ad8\u6548\u7684\u54a8\u8be2\u670d\u52a1\u63d0\u4f9b\u652f\u6301\u3002<\/p><p>\u514d\u8d23\u58f0\u660e\uff1a\u6b64\u8868\u5355\u7528\u4e8e\u6536\u96c6\u60a3\u8005\u4fe1\u606f\uff0c\u4ec5\u4f9b\u5185\u90e8\u4f7f\u7528\u3002\u60a8\u63d0\u4f9b\u7684\u4fe1\u606f\u5c06\u88ab\u4fdd\u5bc6\u5e76\u59a5\u5584\u5904\u7406\u3002<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2e3a6d9a elementor-widget elementor-widget-spacer\" data-id=\"2e3a6d9a\" 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-bd94ce5 elementor-widget elementor-widget-contact-form-7\" data-id=\"bd94ce5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"contact-form-7.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-contact-form-7 jet-elements\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f8871-o1\" lang=\"zh-CN\" dir=\"ltr\" data-wpcf7-id=\"8871\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/cn\/wp-json\/wp\/v2\/pages\/8872#wpcf7-f8871-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=\"8871\" \/><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-f8871-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\" 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 wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-nationality\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span>\u8eab\u9ad8 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-height\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" max=\"999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-height\" \/><\/span><\/span><span> cm <\/span><br \/>\n<span>\u4f53\u91cd \u4ee5\u524d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-pre-weight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-pre-weight\" \/><\/span><\/span><span> kg \u2192 \u73b0\u5728 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-now-weight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-now-weight\" \/><\/span><\/span><span> kg (\u5dee <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-weight-difference\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-weight-difference\" \/><\/span><\/span><span> kg)<\/span>\n\t<\/p>\n\t<p><span class=\"required\">\u5730\u5740<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-address\"><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-address\" \/><\/span><br \/>\n<span class=\"required\">\u7535\u8bdd\u53f7\u7801<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"your-phone-number\" \/><\/span><br \/>\n<span class=\"required\">\u7535\u5b50\u90ae\u4ef6\u5730\u5740<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u764c\u75c7\u75c5\u53f2<\/span><br \/>\n<span class=\"section required\">\u764c\u75c7\u90e8\u4f4d <\/span> (\u8bf7\u52fe\u9009\u6240\u6709\u9002\u7528\u7684\u9879\u3002) <span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-location\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u4e73\u623f\" \/><span class=\"wpcf7-list-item-label\">\u4e73\u623f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u80ba\" \/><span class=\"wpcf7-list-item-label\">\u80ba<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u524d\u5217\u817a\" \/><span class=\"wpcf7-list-item-label\">\u524d\u5217\u817a<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u5927\u80a0\" \/><span class=\"wpcf7-list-item-label\">\u5927\u80a0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u80c3\" \/><span class=\"wpcf7-list-item-label\">\u80c3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u809d\u810f\" \/><span class=\"wpcf7-list-item-label\">\u809d\u810f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u80f0\u810f\" \/><span class=\"wpcf7-list-item-label\">\u80f0\u810f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u76ae\u80a4\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u80a4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u5927\u8111\" \/><span class=\"wpcf7-list-item-label\">\u5927\u8111<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u8180\u80f1\" \/><span class=\"wpcf7-list-item-label\">\u8180\u80f1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u8840\u6db2\" \/><span class=\"wpcf7-list-item-label\">\u8840\u6db2<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"section required\">\u764c\u75c7\u5206\u671f <\/span><span> <span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-stage\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"cancer-history-stage\"><option value=\"\">&#8212;\u8bf7\u9009\u62e9&#8212;<\/option><option value=\"\u7b2c0\u671f\">\u7b2c0\u671f<\/option><option value=\"\u7b2cI\u671f\">\u7b2cI\u671f<\/option><option value=\"\u7b2cII\u671f\">\u7b2cII\u671f<\/option><option value=\"\u7b2cIII\u671f\">\u7b2cIII\u671f<\/option><option value=\"\u7b2cIV\u671f\">\u7b2cIV\u671f<\/option><option value=\"\u4e0d\u660e\">\u4e0d\u660e<\/option><\/select><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section\">\u764c\u75c7\u6cbb\u7597 <\/span><span> \u8bf7\u9009\u62e9\u60a8\u5df2\u63a5\u53d7\u7684\u764c\u75c7\u6cbb\u7597\u3002<\/span><br \/>\n<span class=\"subsection required\">\u624b\u672f\u5386\u53f2<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-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=\"cancer-history-surgery\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-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=\"cancer-history-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=\"cancer-history-surgery-year\" \/><\/span><\/span><span class=\"heading\">\u624b\u672f\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-surgery-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-surgery-location\" \/><\/span><\/span><br \/>\n<span class=\"subsection required\">\u5316\u5b66\u7597\u6cd5<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy\"><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=\"cancer-history-chemotherapy\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection\">\u6301\u7eed\u65f6\u95f4(\u5e74) <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-from\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-chemotherapy-from\" \/><\/span><\/span><span> \u5e74 \u5230 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-to\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-chemotherapy-to\" \/><\/span><\/span><span> \u5e74<\/span><br \/>\n<span>\u836f\u54c1\u540d\u79f0 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-medication\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u70f7\u57fa\u5316\u5242\" \/><span class=\"wpcf7-list-item-label\">\u70f7\u57fa\u5316\u5242<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u4ee3\u8c22\u62ee\u6297\u836f\" \/><span class=\"wpcf7-list-item-label\">\u4ee3\u8c22\u62ee\u6297\u836f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u6297\u80bf\u7624\u6297\u751f\u7d20\" \/><span class=\"wpcf7-list-item-label\">\u6297\u80bf\u7624\u6297\u751f\u7d20<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u62d3\u6251\u5f02\u6784\u9176\u6291\u5236\u5242\" \/><span class=\"wpcf7-list-item-label\">\u62d3\u6251\u5f02\u6784\u9176\u6291\u5236\u5242<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u6709\u4e1d\u5206\u88c2\u6291\u5236\u836f\" \/><span class=\"wpcf7-list-item-label\">\u6709\u4e1d\u5206\u88c2\u6291\u5236\u836f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u6548\u679c <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-effectiveness\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"cancer-history-chemotherapy-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><br \/>\n<span>\u526f\u4f5c\u7528 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-chemotherapy-sideeffects\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u5455\u5410\u30fb\u6076\u5fc3\" \/><span class=\"wpcf7-list-item-label\">\u5455\u5410\u30fb\u6076\u5fc3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u8131\u53d1\" \/><span class=\"wpcf7-list-item-label\">\u8131\u53d1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u4f53\u91cd\u51cf\u8f7b\" \/><span class=\"wpcf7-list-item-label\">\u4f53\u91cd\u51cf\u8f7b<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u8179\u6cfb\" \/><span class=\"wpcf7-list-item-label\">\u8179\u6cfb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u4fbf\u79d8\" \/><span class=\"wpcf7-list-item-label\">\u4fbf\u79d8<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u9ebb\u6728\" \/><span class=\"wpcf7-list-item-label\">\u9ebb\u6728<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u8d2b\u8840\" \/><span class=\"wpcf7-list-item-label\">\u8d2b\u8840<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u611f\u67d3\u75c7\" \/><span class=\"wpcf7-list-item-label\">\u611f\u67d3\u75c7<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u51fa\u8840\" \/><span class=\"wpcf7-list-item-label\">\u51fa\u8840<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u53e3\u8154\u6e83\u75a1\" \/><span class=\"wpcf7-list-item-label\">\u53e3\u8154\u6e83\u75a1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u76ae\u80a4\u75be\u75c5\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u80a4\u75be\u75c5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u6307\u7532\u53d8\u5316\" \/><span class=\"wpcf7-list-item-label\">\u6307\u7532\u53d8\u5316<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">\u653e\u5c04\u6cbb\u7597 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy\"><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=\"cancer-history-radiotherapy\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u653e\u5c04\u6cbb\u7597\u7c7b\u578b <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u7535\u5b50\u675f\" \/><span class=\"wpcf7-list-item-label\">\u7535\u5b50\u675f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"X\u5c04\u7ebf(IMRT\/IGRT)\" \/><span class=\"wpcf7-list-item-label\">X\u5c04\u7ebf(IMRT\/IGRT)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u8d5b\u535a\u5200\" \/><span class=\"wpcf7-list-item-label\">\u8d5b\u535a\u5200<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u4f3d\u9a6c\u5200\" \/><span class=\"wpcf7-list-item-label\">\u4f3d\u9a6c\u5200<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u8d28\u5b50\u675f\" \/><span class=\"wpcf7-list-item-label\">\u8d28\u5b50\u675f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u91cd\u79bb\u5b50\u675f\" \/><span class=\"wpcf7-list-item-label\">\u91cd\u79bb\u5b50\u675f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u4f53\u5185\u7167\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u4f53\u5185\u7167\u5c04<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u8154\u5185\u7167\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u8154\u5185\u7167\u5c04<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u5185\u7528\u7597\u6cd5\" \/><span class=\"wpcf7-list-item-label\">\u5185\u7528\u7597\u6cd5<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u6301\u7eed\u65f6\u95f4(\u5e74) <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-from\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-radiotherapy-from\" \/><\/span><\/span><span> \u5e74 \u5230 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-to\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-radiotherapy-to\" \/><\/span><\/span><span> \u5e74<\/span><br \/>\n<span class=\"heading\">\u6cbb\u7597\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-radiotherapy-location\" \/><\/span><\/span><br \/>\n<span>\u6cbb\u7597\u6548\u679c <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-effectiveness\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"cancer-history-radiotherapy-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><br \/>\n<span>\u526f\u4f5c\u7528 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-radiotherapy-sideeffects\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u5455\u5410\u30fb\u6076\u5fc3\" \/><span class=\"wpcf7-list-item-label\">\u5455\u5410\u30fb\u6076\u5fc3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u8131\u53d1\" \/><span class=\"wpcf7-list-item-label\">\u8131\u53d1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u8179\u6cfb\" \/><span class=\"wpcf7-list-item-label\">\u8179\u6cfb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u53e3\u8154\u6e83\u75a1\" \/><span class=\"wpcf7-list-item-label\">\u53e3\u8154\u6e83\u75a1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u53e3\u8154\u5e72\u71e5\" \/><span class=\"wpcf7-list-item-label\">\u53e3\u8154\u5e72\u71e5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u5473\u89c9\u969c\u788d\" \/><span class=\"wpcf7-list-item-label\">\u5473\u89c9\u969c\u788d<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u541e\u54bd\u56f0\u96be(\u98df\u7ba1\u708e)\" \/><span class=\"wpcf7-list-item-label\">\u541e\u54bd\u56f0\u96be(\u98df\u7ba1\u708e)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u80ba\u708e\" \/><span class=\"wpcf7-list-item-label\">\u80ba\u708e<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u76ae\u80a4\u53d1\u7ea2\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u80a4\u53d1\u7ea2<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u76ae\u80a4\u8131\u76ae\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u80a4\u8131\u76ae<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u76ae\u80a4\u708e(\u7c7b\u4f3c\u6652\u4f24)\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u80a4\u708e(\u7c7b\u4f3c\u6652\u4f24)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">\u514d\u75ab\u6cbb\u7597 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy\"><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=\"cancer-history-immunotherapy\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy\" value=\"\u5426\" \/><span class=\"wpcf7-list-item-label\">\u5426<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u514d\u75ab\u6cbb\u7597\u7c7b\u578b <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"ANK\" \/><span class=\"wpcf7-list-item-label\">ANK<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"DC(\u6811\u7a81\u72b6\u7ec6\u80de)\" \/><span class=\"wpcf7-list-item-label\">DC(\u6811\u7a81\u72b6\u7ec6\u80de)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"\u6d3b\u6027\u5316\u6dcb\u5df4\u7ec6\u80de\" \/><span class=\"wpcf7-list-item-label\">\u6d3b\u6027\u5316\u6dcb\u5df4\u7ec6\u80de<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"\u764c\u75c7\u75ab\u82d7\" \/><span class=\"wpcf7-list-item-label\">\u764c\u75c7\u75ab\u82d7<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u6301\u7eed\u65f6\u95f4(\u5e74) <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy-from\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-immunotherapy-from\" \/><\/span><\/span><span> \u5e74 \u5230 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy-to\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length4\" min=\"1000\" max=\"9999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"cancer-history-immunotherapy-to\" \/><\/span><\/span><span> \u5e74<\/span><br \/>\n<span>\u514d\u75ab\u68c0\u67e5\u70b9\u6291\u5236\u5242 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-immunotherapy-immunecheckpointinhabitors\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u6b27\u5fc5\u535a(Opdivo)\" \/><span class=\"wpcf7-list-item-label\">\u6b27\u5fc5\u535a(Opdivo)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u57fa\u7279\u9c81\u8fbe(Keytruda)\" \/><span class=\"wpcf7-list-item-label\">\u57fa\u7279\u9c81\u8fbe(Keytruda)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u96c5\u6c83\u4f0a(Yervoy)\" \/><span class=\"wpcf7-list-item-label\">\u96c5\u6c83\u4f0a(Yervoy)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u827e\u7f8e\u82ac\u5947(Imfinzi)\" \/><span class=\"wpcf7-list-item-label\">\u827e\u7f8e\u82ac\u5947(Imfinzi)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u68ee\u7279\u529b\u514b(Cemiplimab)\" \/><span class=\"wpcf7-list-item-label\">\u68ee\u7279\u529b\u514b(Cemiplimab)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u5df4\u6587\u63d0\u5965(Bavencio)\" \/><span class=\"wpcf7-list-item-label\">\u5df4\u6587\u63d0\u5965(Bavencio)<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">\u76ee\u524d\u4f7f\u7528\u7684\u764c\u75c7\u836f\u7269 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-current-cancer-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=\"cancer-history-current-cancer-medications\" value=\"\u662f\" \/><span class=\"wpcf7-list-item-label\">\u662f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications\" 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=\"cancer-history-current-cancer-medications-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u987a\u94c2(Cisplatin)\" \/><span class=\"wpcf7-list-item-label\">\u987a\u94c2(Cisplatin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u591a\u67d4\u6bd4\u661f(Doxorubicin)\" \/><span class=\"wpcf7-list-item-label\">\u591a\u67d4\u6bd4\u661f(Doxorubicin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u66f2\u59a5\u73e0\u5355\u6297(\u8d6b\u8d5b\u6c40\uff0cHerceptin)\" \/><span class=\"wpcf7-list-item-label\">\u66f2\u59a5\u73e0\u5355\u6297(\u8d6b\u8d5b\u6c40\uff0cHerceptin)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u5c3c\u4f0f\u5355\u6297(\u6b27\u5fc5\u535a\uff0cNivolumab\uff0cOpdivo)\" \/><span class=\"wpcf7-list-item-label\">\u5c3c\u4f0f\u5355\u6297(\u6b27\u5fc5\u535a\uff0cNivolumab\uff0cOpdivo)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u4ed6\u83ab\u6614\u82ac(Tamoxifen)\" \/><span class=\"wpcf7-list-item-label\">\u4ed6\u83ab\u6614\u82ac(Tamoxifen)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u62c9\u5e15\u66ff\u5c3c(Lapatinib)\" \/><span class=\"wpcf7-list-item-label\">\u62c9\u5e15\u66ff\u5c3c(Lapatinib)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection\">\u5176\u4ed6\u836f\u7269\u548c\u4fdd\u5065\u836f\u54c1<\/span><br \/>\n<span>\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\u3002<\/span><br \/>\n<span class=\"required\">\u6297\u8840\u5c0f\u677f\u836f\u7269 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-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=\"cancer-history-blood-thinners\" value=\"\u6709\" \/><span class=\"wpcf7-list-item-label\">\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-blood-thinners\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-blood-thinners-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-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=\"cancer-history-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=\"cancer-history-blood-thinning-supplements\" value=\"\u6709\" \/><span class=\"wpcf7-list-item-label\">\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-blood-thinning-supplements\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-blood-thinning-supplements-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-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=\"cancer-history-hypertension\"><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=\"cancer-history-hypertension\" value=\"\u6709\" \/><span class=\"wpcf7-list-item-label\">\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-hypertension\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-hypertension-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-hypertension-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">\u7cd6\u5c3f\u75c5\u836f\u7269 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-diabetes\"><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=\"cancer-history-diabetes\" value=\"\u6709\" \/><span class=\"wpcf7-list-item-label\">\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-diabetes\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-diabetes-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-diabetes-text\" \/><\/span><\/span><br \/>\n<span class=\"required\">\u8102\u8d28\u5f02\u5e38\u75c7\/\u9ad8\u8102\u8840\u75c7\/\u80c6\u56fa\u9187 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-dyslipidemia\"><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=\"cancer-history-dyslipidemia\" value=\"\u6709\" \/><span class=\"wpcf7-list-item-label\">\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-dyslipidemia\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><\/span><\/span><\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-dyslipidemia-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-dyslipidemia-text\" \/><\/span><\/span><br \/>\n<span>\u5176\u4ed6 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-other-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-other-text\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection 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 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><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(\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=\"subsection required\">\u8f6c\u79fb <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-metastasis\"><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=\"cancer-history-metastasis\" value=\"\u6709\" \/><span class=\"wpcf7-list-item-label\">\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-metastasis\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u8f6c\u79fb\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-metastasis-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-metastasis-location\" \/><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section\">\u75bc\u75db\u8bc4\u4f30<\/span><br \/>\n<span class=\"subsection required\">\u75bc\u75db\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-pain-assessment-location\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-location[]\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-location[]\" value=\"\u80f8\u90e8\" \/><span class=\"wpcf7-list-item-label\">\u80f8\u90e8<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-location[]\" value=\"\u8179\u90e8\" \/><span class=\"wpcf7-list-item-label\">\u8179\u90e8<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-location[]\" value=\"\u80cc\u90e8\" \/><span class=\"wpcf7-list-item-label\">\u80cc\u90e8<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-location[]\" value=\"\u5173\u8282\" \/><span class=\"wpcf7-list-item-label\">\u5173\u8282<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-location[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u75bc\u75db\u5f3a\u5ea6\uff0c\u8bf7\u75281\u523010\u7684\u5206\u503c\u8868\u793a\u3002<\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-pain-assessment-scale\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"cancer-history-pain-assessment-scale\"><option value=\"\">&#8212;\u8bf7\u9009\u62e9&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><\/select><\/span><\/span><span>(1=\u5b8c\u5168\u6ca1\u6709\u75bc\u75db\u300110=\u75bc\u75db\u96be\u5fcd) <\/span><br \/>\n<span class=\"subsection\">\u75bc\u75db\u7c7b\u578b <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-pain-assessment-type\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-type[]\" value=\"\u950b\u5229\u7684\" \/><span class=\"wpcf7-list-item-label\">\u950b\u5229\u7684<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-type[]\" value=\"\u949d\u75db\" \/><span class=\"wpcf7-list-item-label\">\u949d\u75db<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-type[]\" value=\"\u8df3\u75db\" \/><span class=\"wpcf7-list-item-label\">\u8df3\u75db<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-type[]\" value=\"\u70e7\u707c\u75db\" \/><span class=\"wpcf7-list-item-label\">\u70e7\u707c\u75db<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-type[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection\">\u75bc\u75db\u6301\u7eed\u65f6\u95f4\u548c\u9891\u7387 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-pain-assessment-frequency\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-frequency[]\" value=\"\u4e00\u76f4\u6709\" \/><span class=\"wpcf7-list-item-label\">\u4e00\u76f4\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-frequency[]\" value=\"\u5076\u5c14\" \/><span class=\"wpcf7-list-item-label\">\u5076\u5c14<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-frequency[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u75bc\u75db\u7f13\u89e3\u65b9\u6cd5 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-pain-assessment-anyrelief-measures\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-anyrelief-measures[]\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-anyrelief-measures[]\" value=\"\u975e\u753e\u4f53\u6297\u708e\u836f\uff08NSAIDS\uff09\" \/><span class=\"wpcf7-list-item-label\">\u975e\u753e\u4f53\u6297\u708e\u836f\uff08NSAIDS\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-anyrelief-measures[]\" value=\"\u5bf9\u4e59\u9170\u6c28\u57fa\u915a\uff08\u6251\u70ed\u606f\u75db\uff09\" \/><span class=\"wpcf7-list-item-label\">\u5bf9\u4e59\u9170\u6c28\u57fa\u915a\uff08\u6251\u70ed\u606f\u75db\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-anyrelief-measures[]\" value=\"\u9ebb\u9189\u836f\" \/><span class=\"wpcf7-list-item-label\">\u9ebb\u9189\u836f<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-anyrelief-measures[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/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 required\">\u8fc7\u53bb\u75c5\u53f2 <\/span> (\u8bf7\u52fe\u9009\u66fe\u7ecf\u60a3\u8fc7\u7684\u75be\u75c5\u3002)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medical-history\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u8d2b\u8840\" \/><span class=\"wpcf7-list-item-label\">\u8d2b\u8840<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u7126\u8651\u75c7\" \/><span class=\"wpcf7-list-item-label\">\u7126\u8651\u75c7<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u5173\u8282\u708e\" \/><span class=\"wpcf7-list-item-label\">\u5173\u8282\u708e<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u54ee\u5598\" \/><span class=\"wpcf7-list-item-label\">\u54ee\u5598<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u8fc7\u654f\" \/><span class=\"wpcf7-list-item-label\">\u8fc7\u654f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u8840\u6db2\u51dd\u56fa\u969c\u788d\" \/><span class=\"wpcf7-list-item-label\">\u8840\u6db2\u51dd\u56fa\u969c\u788d<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u5934\u75db\" \/><span class=\"wpcf7-list-item-label\">\u5934\u75db<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" 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=\"medical-history[]\" 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=\"medical-history[]\" value=\"\u9aa8\u8d28\u758f\u677e\" \/><span class=\"wpcf7-list-item-label\">\u9aa8\u8d28\u758f\u677e<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u53d1\u4f5c\uff08\u5305\u62ec\u62bd\u6410\uff09\" \/><span class=\"wpcf7-list-item-label\">\u53d1\u4f5c\uff08\u5305\u62ec\u62bd\u6410\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u4e2d\u98ce\" \/><span class=\"wpcf7-list-item-label\">\u4e2d\u98ce<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"HIV\/AIDS\uff08\u827e\u6ecb\u75c5\uff09\" \/><span class=\"wpcf7-list-item-label\">HIV\/AIDS\uff08\u827e\u6ecb\u75c5\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u7532\u72b6\u817a\u529f\u80fd\u4f4e\u4e0b\u75c7\" \/><span class=\"wpcf7-list-item-label\">\u7532\u72b6\u817a\u529f\u80fd\u4f4e\u4e0b\u75c7<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u9ad8\u8840\u538b\" \/><span class=\"wpcf7-list-item-label\">\u9ad8\u8840\u538b<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u9ad8\u8102\u8840\u75c7\uff08\u9ad8\u80c6\u56fa\u9187\uff09\" \/><span class=\"wpcf7-list-item-label\">\u9ad8\u8102\u8840\u75c7\uff08\u9ad8\u80c6\u56fa\u9187\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" 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=\"medical-history[]\" 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=\"medical-history[]\" value=\"\u7ed3\u6838\" \/><span class=\"wpcf7-list-item-label\">\u7ed3\u6838<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u6e83\u75a1\" \/><span class=\"wpcf7-list-item-label\">\u6e83\u75a1<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><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=\"part\">\u65e5\u5e38\u751f\u6d3b\u6d3b\u52a8\u80fd\u529b\u8bc4\u4f30<\/span><br \/>\n<span class=\"section required\">\u79fb\u52a8\u529f\u80fd <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"daily-living-activities-mobility\"><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=\"daily-living-activities-mobility\" value=\"\u53ef\u4ee5\u72ec\u7acb\u5b8c\u6210\" \/><span class=\"wpcf7-list-item-label\">\u53ef\u4ee5\u72ec\u7acb\u5b8c\u6210<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"daily-living-activities-mobility\" value=\"\u4e0d\u80fd\u72ec\u7acb\u5b8c\u6210\" \/><span class=\"wpcf7-list-item-label\">\u4e0d\u80fd\u72ec\u7acb\u5b8c\u6210<\/span><\/label><\/span><\/span><\/span><\/span><span>\u5982\u679c\u9009\u62e9\u201c\u4e0d\u80fd\u72ec\u7acb\u5b8c\u6210\u201d\u3001\u8bf7\u8bf4\u660e\u5177\u4f53\u7c7b\u578b <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"daily-living-activities-mobility-no\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"daily-living-activities-mobility-no[]\" value=\"\u52a9\u884c\u5668\" \/><span class=\"wpcf7-list-item-label\">\u52a9\u884c\u5668<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"daily-living-activities-mobility-no[]\" value=\"\u8f6e\u6905\" \/><span class=\"wpcf7-list-item-label\">\u8f6e\u6905<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"daily-living-activities-mobility-no[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"section required\">\u4f7f\u7528\u5bfc\u7ba1 <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"daily-living-activities-catheter\"><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=\"daily-living-activities-catheter\" value=\"\u6709\" \/><span class=\"wpcf7-list-item-label\">\u6709<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"daily-living-activities-catheter\" value=\"\u65e0\" \/><span class=\"wpcf7-list-item-label\">\u65e0<\/span><\/label><\/span><\/span><\/span><\/span><span> \u5982\u679c\u9009\u62e9\u201c\u6709\u201d\uff0c\u8bf7\u8bf4\u660e\u7c7b\u578b <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"daily-living-activities-catheter-yes\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"daily-living-activities-catheter-yes[]\" value=\"\u5c3f\u9053\u5bfc\u7ba1\" \/><span class=\"wpcf7-list-item-label\">\u5c3f\u9053\u5bfc\u7ba1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"daily-living-activities-catheter-yes[]\" value=\"\u7ecf\u7ba1\u8425\u517b\u7ba1\" \/><span class=\"wpcf7-list-item-label\">\u7ecf\u7ba1\u8425\u517b\u7ba1<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"daily-living-activities-catheter-yes[]\" value=\"\u5176\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u5176\u4ed6<\/span><\/label><\/span><\/span><\/span> <\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u5bb6\u65cf\u764c\u75c7\u75c5\u53f2\uff1a<\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-father\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-father[]\" value=\"\u7236\u4eb2\" \/><span class=\"wpcf7-list-item-label\">\u7236\u4eb2<\/span><\/label><\/span><\/span><\/span><\/span><span>\u764c\u75c7\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-father-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-father-location\" \/><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-mother\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-mother[]\" value=\"\u6bcd\u4eb2\" \/><span class=\"wpcf7-list-item-label\">\u6bcd\u4eb2<\/span><\/label><\/span><\/span><\/span><\/span><span>\u764c\u75c7\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-mother-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-mother-location\" \/><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-grandfather\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-grandfather[]\" value=\"\u7956\u7236\" \/><span class=\"wpcf7-list-item-label\">\u7956\u7236<\/span><\/label><\/span><\/span><\/span><\/span><span>\u764c\u75c7\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-grandfather-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-grandfather-location\" \/><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-grandmother\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-grandmother[]\" value=\"\u7956\u6bcd\" \/><span class=\"wpcf7-list-item-label\">\u7956\u6bcd<\/span><\/label><\/span><\/span><\/span><\/span><span>\u764c\u75c7\u90e8\u4f4d <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-grandmother-location\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-grandmother-location\" \/><\/span><\/span><br \/>\n<span><span class=\"wpcf7-form-control-wrap\" data-name=\"cancer-history-family-other\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"cancer-history-family-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=\"cancer-history-family-other-text\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cancer-history-family-other-text\" \/><\/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 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