{"id":9161,"date":"2026-02-25T00:00:36","date_gmt":"2026-02-24T15:00:36","guid":{"rendered":"https:\/\/mrclinic.tokyo\/jp\/?page_id=9161"},"modified":"2026-03-12T15:07:50","modified_gmt":"2026-03-12T06:07:50","slug":"regenerative-treatment-questionnaire","status":"publish","type":"page","link":"https:\/\/mrclinic.tokyo\/jp\/regenerative-treatment-questionnaire\/","title":{"rendered":"\u518d\u751f\u533b\u7642\u306b\u95a2\u3059\u308b\u554f\u8a3a\u7968"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9161\" class=\"elementor elementor-9161\">\n\t\t\t\t<div class=\"elementor-element elementor-element-78cf58f2 e-flex e-con-boxed e-con e-parent\" data-id=\"78cf58f2\" 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-9a04141 e-con-full e-flex e-con e-child\" data-id=\"9a04141\" 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-222383f8 elementor-widget elementor-widget-spacer\" data-id=\"222383f8\" 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-35f64117 elementor-widget elementor-widget-heading\" data-id=\"35f64117\" 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\u7642\u306b\u95a2\u3059\u308b\u554f\u8a3a\u7968<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7bccc705 elementor-widget elementor-widget-text-editor\" data-id=\"7bccc705\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div 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class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\u203b\u514d\u8cac\u4e8b\u9805\uff1a\u3053\u306e\u30d5\u30a9\u30fc\u30e0\u306f\u60a3\u8005\u69d8\u306b\u95a2\u3059\u308b\u60c5\u5831\u3092\u53ce\u96c6\u3057\u3001\u5185\u90e8\u76ee\u7684\u306e\u307f\u306b\u4f7f\u7528\u3055\u308c\u307e\u3059\u3002\u3054\u63d0\u4f9b\u3044\u305f\u3060\u3044\u305f\u60c5\u5831\u306f\u6a5f\u5bc6\u60c5\u5831\u3068\u3057\u3066\u53d6\u308a\u6271\u308f\u308c\u307e\u3059\u3002\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-73b69fff elementor-widget elementor-widget-spacer\" data-id=\"73b69fff\" 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-750f61d elementor-widget elementor-widget-contact-form-7\" data-id=\"750f61d\" 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-f9095-o1\" lang=\"ja\" dir=\"ltr\" data-wpcf7-id=\"9095\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/jp\/wp-json\/wp\/v2\/pages\/9161#wpcf7-f9095-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"\u30b3\u30f3\u30bf\u30af\u30c8\u30d5\u30a9\u30fc\u30e0\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"9095\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"ja\" 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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\">\u751f\u5e74\u6708\u65e5 <\/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\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-age\" \/><\/span><\/span><span> \u6b73)<\/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\u9577 <\/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><span class=\"rindent\">\u4f53\u91cd <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-weight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" min=\"0\" max=\"999\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-weight\" \/><\/span><\/span><span>kg<\/span>\n\t<\/p>\n\t<p><span class=\"required\">\u4f4f\u6240<\/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\">\u96fb\u8a71\u756a\u53f7<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-phonenumber\"><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-phonenumber\" \/><\/span><br \/>\n<span class=\"required\">\u30e1\u30fc\u30eb\u30a2\u30c9\u30ec\u30b9<\/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\">\u6539\u5584\u3057\u305f\u3044\u61f8\u5ff5\u4e8b\u9805<\/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\u6a5f\u80fd\" \/><span class=\"wpcf7-list-item-label\">\u809d\u6a5f\u80fd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u814e\u6a5f\u80fd\" \/><span class=\"wpcf7-list-item-label\">\u814e\u6a5f\u80fd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u6027\u6a5f\u80fd\" \/><span class=\"wpcf7-list-item-label\">\u6027\u6a5f\u80fd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u7f8e\u5bb9\uff08\u808c\u30fb\u80b2\u6bdb\uff09\" \/><span class=\"wpcf7-list-item-label\">\u7f8e\u5bb9\uff08\u808c\u30fb\u80b2\u6bdb\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"want-improve[]\" value=\"\u8a8d\u77e5\u6a5f\u80fd\u4f4e\u4e0b\u4e88\u9632\" \/><span class=\"wpcf7-list-item-label\">\u8a8d\u77e5\u6a5f\u80fd\u4f4e\u4e0b\u4e88\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=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\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\">\u4ed6\u306e\u75c5\u9662\u3067\u53d7\u3051\u305f\u6cbb\u7642<\/span><br \/>\n<span class=\"section required\">\u624b\u8853\u6b74<\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-surgery\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u624b\u8853\u3092\u53d7\u3051\u305f\u5e74 <\/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>\u5e74<\/span><span class=\"rindent\">\u624b\u8853\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\">\u30a2\u30f3\u30c1\u30a8\u30fc\u30b8\u30f3\u30b0 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/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=\"\u30d2\u30a2\u30eb\u30ed\u30f3\u6ce8\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u30d2\u30a2\u30eb\u30ed\u30f3\u6ce8\u5c04<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u30dc\u30c8\u30c3\u30af\u30b9\u6ce8\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u30dc\u30c8\u30c3\u30af\u30b9\u6ce8\u5c04<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u30d4\u30fc\u30ea\u30f3\u30b0\" \/><span class=\"wpcf7-list-item-label\">\u30d4\u30fc\u30ea\u30f3\u30b0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u30b9\u30ec\u30c3\u30c9\u30ea\u30d5\u30c8\uff08\u7cf8\u30ea\u30d5\u30c8\uff09\" \/><span class=\"wpcf7-list-item-label\">\u30b9\u30ec\u30c3\u30c9\u30ea\u30d5\u30c8\uff08\u7cf8\u30ea\u30d5\u30c8\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u30ec\u30fc\u30b6\u30fc\u6cbb\u7642\" \/><span class=\"wpcf7-list-item-label\">\u30ec\u30fc\u30b6\u30fc\u6cbb\u7642<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-antiaging-items[]\" value=\"\u8102\u80aa\u5438\u5f15\" \/><span class=\"wpcf7-list-item-label\">\u8102\u80aa\u5438\u5f15<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">\u518d\u751f\u533b\u7642 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u3044\u3064\u6cbb\u7642\u3092\u53d7\u3051\u307e\u3057\u305f\u304b\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\u7642\u5185\u5bb9 <\/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\u7642\" \/><span class=\"wpcf7-list-item-label\">\u4e0a\u6e05\u6db2\u6cbb\u7642<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-treatment[]\" value=\"\u5e79\u7d30\u80de\u6cbb\u7642\" \/><span class=\"wpcf7-list-item-label\">\u5e79\u7d30\u80de\u6cbb\u7642<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u3069\u3053\u3067\u6cbb\u7642\u3092\u53d7\u3051\u307e\u3057\u305f\u304b\uff1f<\/span><br \/>\n<span>\u56fd <\/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;\u4ee5\u4e0b\u304b\u3089\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044&#8212;<\/option><option value=\"\u30c9\u30d0\u30a4(UAE)\">\u30c9\u30d0\u30a4(UAE)<\/option><option value=\"\u97d3\u56fd\">\u97d3\u56fd<\/option><option value=\"\u30de\u30ec\u30fc\u30b7\u30a2\">\u30de\u30ec\u30fc\u30b7\u30a2<\/option><option value=\"\u30e1\u30ad\u30b7\u30b3\">\u30e1\u30ad\u30b7\u30b3<\/option><option value=\"\u30bf\u30a4\">\u30bf\u30a4<\/option><option value=\"\u30a6\u30af\u30e9\u30a4\u30ca\">\u30a6\u30af\u30e9\u30a4\u30ca<\/option><option value=\"\u305d\u306e\u4ed6\">\u305d\u306e\u4ed6<\/option><\/select><\/span><\/span><span class=\"rindent\">\u305d\u306e\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>\u30a8\u30ea\u30a2 <\/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 class=\"rindent\"> \u75c5\u9662\u540d <\/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>\u5e79\u7d30\u80de\u7642\u6cd5\u306e\u8a73\u7d30\u3092\u3054\u8a18\u5165\u304f\u3060\u3055\u3044\uff08\u8a72\u5f53\u3059\u308b\u5834\u5408\uff09<\/span><br \/>\n<span>\u6295\u4e0e\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=\"\u70b9\u6ef4\" \/><span class=\"wpcf7-list-item-label\">\u70b9\u6ef4<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-regenerative-stemcell-method[]\" value=\"\u5c40\u6240\u6ce8\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u5c40\u6240\u6ce8\u5c04<\/span><\/label><\/span><\/span><\/span><\/span><span class=\"rindent\">\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>\u6295\u4e0e\u56de\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>\u56de<\/span><br \/>\n<span>\u5e79\u7d30\u80de\u6570 <\/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;\u4ee5\u4e0b\u304b\u3089\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044&#8212;<\/option><option value=\"\u6539\u5584\">\u6539\u5584<\/option><option value=\"\u60aa\u5316\">\u60aa\u5316<\/option><option value=\"\u5909\u5316\u306a\u3057\">\u5909\u5316\u306a\u3057<\/option><\/select><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"required\">\u75db\u307f\u306e\u6cbb\u7642 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/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=\"\u30ab\u30a4\u30ed\u30d7\u30e9\u30af\u30c6\u30a3\u30c3\u30af\" \/><span class=\"wpcf7-list-item-label\">\u30ab\u30a4\u30ed\u30d7\u30e9\u30af\u30c6\u30a3\u30c3\u30af<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"\u937c\u7078\" \/><span class=\"wpcf7-list-item-label\">\u937c\u7078<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"treatment-another-hospital-pain-detail[]\" value=\"\u30de\u30c3\u30b5\u30fc\u30b8\" \/><span class=\"wpcf7-list-item-label\">\u30de\u30c3\u30b5\u30fc\u30b8<\/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\">\u305d\u306e\u4ed6\uff1a<\/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\">\u4ed6\u306e\u75c5\u9662\u304b\u3089\u306e\u30c7\u30fc\u30bf <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/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=\"\u8a3a\u65ad\u66f8\" \/><span class=\"wpcf7-list-item-label\">\u8a3a\u65ad\u66f8<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u6cbb\u7642\u7d4c\u904e\u8a18\u9332\" \/><span class=\"wpcf7-list-item-label\">\u6cbb\u7642\u7d4c\u904e\u8a18\u9332<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u8840\u6db2\u691c\u67fb\u7d50\u679c\" \/><span class=\"wpcf7-list-item-label\">\u8840\u6db2\u691c\u67fb\u7d50\u679c<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"X\u7dda\" \/><span class=\"wpcf7-list-item-label\">X\u7dda<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"CT\u30b9\u30ad\u30e3\u30f3\" \/><span class=\"wpcf7-list-item-label\">CT\u30b9\u30ad\u30e3\u30f3<\/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\u30b9\u30ad\u30e3\u30f3\" \/><span class=\"wpcf7-list-item-label\">PET\u30b9\u30ad\u30e3\u30f3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u624b\u8853\u8a18\u9332\" \/><span class=\"wpcf7-list-item-label\">\u624b\u8853\u8a18\u9332<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u653e\u5c04\u7dda\u6cbb\u7642\u8a18\u9332\" \/><span class=\"wpcf7-list-item-label\">\u653e\u5c04\u7dda\u6cbb\u7642\u8a18\u9332<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u5316\u5b66\u7642\u6cd5\u8a18\u9332\" \/><span class=\"wpcf7-list-item-label\">\u5316\u5b66\u7642\u6cd5\u8a18\u9332<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals-items[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u4ed6\u306e\u75c5\u9662\u306e\u8a3a\u7642\u8a18\u9332\u30d5\u30a1\u30a4\u30eb\u304c\u3042\u308b\u5834\u5408\u306f\u3001\u3053\u3061\u3089\u304b\u3089\u30a2\u30c3\u30d7\u30ed\u30fc\u30c9\u3057\u3066\u304f\u3060\u3055\u3044\u3002<br \/>\n(\u753b\u50cf\u30d5\u30a1\u30a4\u30eb\u30fbPDF\u5f62\u5f0f\u300110M\u30d0\u30a4\u30c8\u4ee5\u5185)<\/span><br \/>\n<span>\u8a18\u9332\u30d5\u30a1\u30a4\u30eb <\/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\">\u305d\u306e\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\u7642\u4e2d\u306e\u75c5\u72b6\/\u6301\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=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u9ad8\u8840\u5727\uff08\u9ad8\u8840\u5727\u75c7\uff09\" \/><span class=\"wpcf7-list-item-label\">\u9ad8\u8840\u5727\uff08\u9ad8\u8840\u5727\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\u75be\u60a3\" \/><span class=\"wpcf7-list-item-label\">\u809d\u75be\u60a3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u814e\u75be\u60a3\" \/><span class=\"wpcf7-list-item-label\">\u814e\u75be\u60a3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u5fc3\u75be\u60a3\" \/><span class=\"wpcf7-list-item-label\">\u5fc3\u75be\u60a3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u8133\u51fa\u8840\u30fb\u8133\u6897\u585e\" \/><span class=\"wpcf7-list-item-label\">\u8133\u51fa\u8840\u30fb\u8133\u6897\u585e<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u5598\u606f\u30fbCOPD\" \/><span class=\"wpcf7-list-item-label\">\u5598\u606f\u30fbCOPD<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u514d\u75ab\u75be\u60a3\" \/><span class=\"wpcf7-list-item-label\">\u514d\u75ab\u75be\u60a3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u60aa\u6027\u816b\u760d\" \/><span class=\"wpcf7-list-item-label\">\u60aa\u6027\u816b\u760d<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u7cbe\u795e\u75be\u60a3\" \/><span class=\"wpcf7-list-item-label\">\u7cbe\u795e\u75be\u60a3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u4e0d\u598a\u75c7\" \/><span class=\"wpcf7-list-item-label\">\u4e0d\u598a\u75c7<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"under-treatment[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"required\">\u611f\u67d3\u75c7\u306e\u6cbb\u7642 <\/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=\"\u3042\u308a\" \/><span class=\"wpcf7-list-item-label\">\u3042\u308a<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"under-treatment-infectious\" value=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>(\u3042\u308a\u306e\u5834\u5408) \u4ee5\u4e0b\u306e\u611f\u67d3\u75c7\u306e\u3046\u3061\u3069\u306e\u6cbb\u7642\u3092\u53d7\u3051\u3066\u3044\u307e\u3059\u304b\uff1f (\u8a72\u5f53\u3059\u308b\u3082\u306e\u3092\u3059\u3079\u3066)<\/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=\"\u7d50\u6838\" \/><span class=\"wpcf7-list-item-label\">\u7d50\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\">\u73fe\u5728\u670d\u7528\u4e2d\u306e\u85ac\u30fb\u30b5\u30d7\u30ea\u30e1\u30f3\u30c8<\/span><br \/>\n<span>\u670d\u7528\u3057\u3066\u3044\u308b\u85ac\u306e\u540d\u524d\u3068\u6295\u4e0e\u91cf\uff08\u6709\u52b9\u6210\u5206\u91cf \u4f8b\uff1amg\uff09\u3092\u8a18\u8f09\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/span><br \/>\n<span class=\"required\">\u6297\u8840\u5c0f\u677f\u85ac <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinners\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/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\u30b5\u30e9\u30b5\u30e9\u30b5\u30d7\u30ea\u30e1\u30f3\u30c8 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-supplements-blood-thinning-supplements\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/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\u5727 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-hypertension-medications\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/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 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-diabetes-medications\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/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\u30db\u30eb\u30e2\u30f3\u7642\u6cd5 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-female-hormone-therapy\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/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\u7684\u306a\u85ac <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"current-medications-psychiatric-medications\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/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>\u305d\u306e\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\u6b74<\/span><br \/>\n<span class=\"section required\">\u30a2\u30eb\u30b3\u30fc\u30eb <\/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=\"\u98f2\u307e\u306a\u3044\" \/><span class=\"wpcf7-list-item-label\">\u98f2\u307e\u306a\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"social-history-alcohol\" value=\"\u98f2\u3080\" \/><span class=\"wpcf7-list-item-label\">\u98f2\u3080<\/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;\u4ee5\u4e0b\u304b\u3089\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044&#8212;<\/option><option value=\"\u65e5\u672c\u91521\u676f\">\u65e5\u672c\u91521\u676f<\/option><option value=\"\u30d3\u30fc\u30eb\u5927\u74f61\u672c\">\u30d3\u30fc\u30eb\u5927\u74f61\u672c<\/option><option value=\"\u713c\u914e\/\u6ce1\u76db2\/3\u676f\">\u713c\u914e\/\u6ce1\u76db2\/3\u676f<\/option><option value=\"\u30a6\u30a3\u30b9\u30ad\u30fc\u30c0\u30d6\u30eb\u30b7\u30e7\u30c3\u30c81\u676f\">\u30a6\u30a3\u30b9\u30ad\u30fc\u30c0\u30d6\u30eb\u30b7\u30e7\u30c3\u30c81\u676f<\/option><option value=\"\u30ef\u30a4\u30f31\/3\u672c\">\u30ef\u30a4\u30f31\/3\u672c<\/option><option value=\"\u305d\u308c\u4ee5\u4e0a\">\u305d\u308c\u4ee5\u4e0a<\/option><\/select><\/span><\/span><span> )<\/span><br \/>\n<span class=\"section required\">\u55ab\u7159 <\/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=\"\u55ab\u7159\u3057\u306a\u3044\" \/><span class=\"wpcf7-list-item-label\">\u55ab\u7159\u3057\u306a\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"social-history-tobacco\" value=\"\u55ab\u7159\u3059\u308b\" \/><span class=\"wpcf7-list-item-label\">\u55ab\u7159\u3059\u308b<\/span><\/label><\/span><\/span><\/span><\/span><span> (<\/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> \u672c\/1\u65e5 )<\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u75c5\u6b74<\/span><br \/>\n<span class=\"section\">\u30a2\u30ec\u30eb\u30ae\u30fc <\/span><br \/>\n<span class=\"subsection required\">\u98df\u3079\u7269 <\/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=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u30ad\u30a6\u30a4\" \/><span class=\"wpcf7-list-item-label\">\u30ad\u30a6\u30a4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u30d0\u30ca\u30ca\" \/><span class=\"wpcf7-list-item-label\">\u30d0\u30ca\u30ca<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u30a2\u30dc\u30ab\u30c9\" \/><span class=\"wpcf7-list-item-label\">\u30a2\u30dc\u30ab\u30c9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u30d1\u30d1\u30a4\u30e4\" \/><span class=\"wpcf7-list-item-label\">\u30d1\u30d1\u30a4\u30e4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u30de\u30f3\u30b4\u30fc\" \/><span class=\"wpcf7-list-item-label\">\u30de\u30f3\u30b4\u30fc<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u30e1\u30ed\u30f3\" \/><span class=\"wpcf7-list-item-label\">\u30e1\u30ed\u30f3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u30a4\u30c1\u30b8\u30af\" \/><span class=\"wpcf7-list-item-label\">\u30a4\u30c1\u30b8\u30af<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u30b5\u30af\u30e9\u30f3\u30dc\" \/><span class=\"wpcf7-list-item-label\">\u30b5\u30af\u30e9\u30f3\u30dc<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u5375\" \/><span class=\"wpcf7-list-item-label\">\u5375<\/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=\"\u30d4\u30fc\u30ca\u30c3\u30c4\" \/><span class=\"wpcf7-list-item-label\">\u30d4\u30fc\u30ca\u30c3\u30c4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u9752\u9b5a\" \/><span class=\"wpcf7-list-item-label\">\u9752\u9b5a<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-food[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"indent10\">\u300c\u305d\u306e\u4ed6\u300d\u3092\u9078\u629e\u3055\u308c\u305f\u5834\u5408\u306f\u5177\u4f53\u7684\u306b\u8a18\u5165\u3057\u3066\u304f\u3060\u3055\u3044\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>\u91cd\u75c7\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=\"\u8efd\" \/><span class=\"wpcf7-list-item-label\">\u8efd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"\u4e2d\" \/><span class=\"wpcf7-list-item-label\">\u4e2d<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-food-severity\" value=\"\u91cd\" \/><span class=\"wpcf7-list-item-label\">\u91cd<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u85ac <\/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=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u30a2\u30b9\u30d4\u30ea\u30f3\uff08\u4f8b\uff1a\u30d0\u30d5\u30a1\u30ea\u30f3\uff09\" \/><span class=\"wpcf7-list-item-label\">\u30a2\u30b9\u30d4\u30ea\u30f3\uff08\u4f8b\uff1a\u30d0\u30d5\u30a1\u30ea\u30f3\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u30a4\u30d6\u30d7\u30ed\u30d5\u30a7\u30f3\uff08\u4f8b\uff1a\u30d6\u30eb\u30d5\u30a7\u30f3\u3001\u30a4\u30d6\uff09\" \/><span class=\"wpcf7-list-item-label\">\u30a4\u30d6\u30d7\u30ed\u30d5\u30a7\u30f3\uff08\u4f8b\uff1a\u30d6\u30eb\u30d5\u30a7\u30f3\u3001\u30a4\u30d6\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u30ed\u30ad\u30bd\u30d7\u30ed\u30d5\u30a7\u30f3\uff08\u4f8b\uff1a\u30ed\u30ad\u30bd\u30cb\u30f3\uff09\" \/><span class=\"wpcf7-list-item-label\">\u30ed\u30ad\u30bd\u30d7\u30ed\u30d5\u30a7\u30f3\uff08\u4f8b\uff1a\u30ed\u30ad\u30bd\u30cb\u30f3\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u9ebb\u9154\u85ac\uff08\u4f8b\uff1a\u30ad\u30b7\u30ed\u30ab\u30a4\u30f3\uff09\" \/><span class=\"wpcf7-list-item-label\">\u9ebb\u9154\u85ac\uff08\u4f8b\uff1a\u30ad\u30b7\u30ed\u30ab\u30a4\u30f3\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-medication[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u300c\u305d\u306e\u4ed6\u300d\u306b\u30c1\u30a7\u30c3\u30af\u3057\u305f\u5834\u5408\u3001\u5177\u4f53\u7684\u306a\u85ac\u540d\u3092\u8a18\u8f09\u3057\u3066\u304f\u3060\u3055\u3044\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>\u91cd\u75c7\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=\"\u8efd\" \/><span class=\"wpcf7-list-item-label\">\u8efd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"\u4e2d\" \/><span class=\"wpcf7-list-item-label\">\u4e2d<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-medication-severity\" value=\"\u91cd\" \/><span class=\"wpcf7-list-item-label\">\u91cd<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u6297\u751f\u7269\u8cea\/\u6297\u771f\u83cc\u85ac <\/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=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u30da\u30cb\u30b7\u30ea\u30f3\u7cfb\" \/><span class=\"wpcf7-list-item-label\">\u30da\u30cb\u30b7\u30ea\u30f3\u7cfb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u30bb\u30d5\u30a7\u30e0\u7cfb\uff08\u4f8b\uff1a\u30bb\u30d5\u30be\u30f3\u306a\u3069\uff09\" \/><span class=\"wpcf7-list-item-label\">\u30bb\u30d5\u30a7\u30e0\u7cfb\uff08\u4f8b\uff1a\u30bb\u30d5\u30be\u30f3\u306a\u3069\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u30b9\u30c8\u30ec\u30d7\u30c8\u30de\u30a4\u30b7\u30f3\" \/><span class=\"wpcf7-list-item-label\">\u30b9\u30c8\u30ec\u30d7\u30c8\u30de\u30a4\u30b7\u30f3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u30a2\u30df\u30ab\u30b7\u30f3\" \/><span class=\"wpcf7-list-item-label\">\u30a2\u30df\u30ab\u30b7\u30f3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u30a2\u30df\u30ce\u30b0\u30ea\u30b3\u30b7\u30c9\u7cfb\uff08\u30b9\u30c8\u30ec\u30d7\u30c8\u30de\u30a4\u30b7\u30f3\u3001\u30a2\u30df\u30ab\u30b7\u30f3\u4ee5\u5916\uff09\" \/><span class=\"wpcf7-list-item-label\">\u30a2\u30df\u30ce\u30b0\u30ea\u30b3\u30b7\u30c9\u7cfb\uff08\u30b9\u30c8\u30ec\u30d7\u30c8\u30de\u30a4\u30b7\u30f3\u3001\u30a2\u30df\u30ab\u30b7\u30f3\u4ee5\u5916\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u30a2\u30e0\u30db\u30e9\u30ea\u30b7\u30f3\uff22\" \/><span class=\"wpcf7-list-item-label\">\u30a2\u30e0\u30db\u30e9\u30ea\u30b7\u30f3\uff22<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-antibiotics[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span> <\/span><br \/>\n<span>\u300c\u305d\u306e\u4ed6\u300d\u306b\u30c1\u30a7\u30c3\u30af\u3057\u305f\u5834\u5408\u3001\u5177\u4f53\u7684\u306a\u85ac\u540d\u3092\u8a18\u8f09\u3057\u3066\u304f\u3060\u3055\u3044\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>\u91cd\u75c7\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=\"\u8efd\" \/><span class=\"wpcf7-list-item-label\">\u8efd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"\u4e2d\" \/><span class=\"wpcf7-list-item-label\">\u4e2d<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-antibiotics-severity\" value=\"\u91cd\" \/><span class=\"wpcf7-list-item-label\">\u91cd<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u305d\u306e\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=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"\u30e9\u30c6\u30c3\u30af\u30b9\" \/><span class=\"wpcf7-list-item-label\">\u30e9\u30c6\u30c3\u30af\u30b9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"\u30a2\u30eb\u30b3\u30fc\u30eb\" \/><span class=\"wpcf7-list-item-label\">\u30a2\u30eb\u30b3\u30fc\u30eb<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-other[]\" value=\"\u30e8\u30a6\u7d20\" \/><span class=\"wpcf7-list-item-label\">\u30e8\u30a6\u7d20<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u91cd\u75c7\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=\"\u8efd\" \/><span class=\"wpcf7-list-item-label\">\u8efd<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"\u4e2d\" \/><span class=\"wpcf7-list-item-label\">\u4e2d<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"allergies-other-severity\" value=\"\u91cd\" \/><span class=\"wpcf7-list-item-label\">\u91cd<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">\u6b6f\u79d1\u9ebb\u9154\uff08\u30ad\u30b7\u30ed\u30ab\u30a4\u30f3\uff09\u3084\u80c3\u30ab\u30e1\u30e9\u7b49\u9ebb\u9154\u3067\u6c17\u5206\u304c\u60aa\u304f\u306a\u3063\u305f\u3053\u3068\u304c\u3042\u308a\u307e\u3059\u304b\uff1f<\/span><br \/>\n<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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"anesthesia\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"section required\">\u598a\u5a20\u4e2d\u307e\u305f\u306f\u598a\u5a20\uff083\u304b\u6708\u4ee5\u5185\u306e\u6d41\u7523\u30fb\u4e2d\u7d76\uff09\u306e\u53ef\u80fd\u6027\u304c\u3042\u308a\u307e\u3059\u304b\uff1f<\/span><br \/>\n<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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"pregnancy\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u7dca\u6025\u9023\u7d61\u5148<\/span><br \/>\n<span>\u6c0f\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>\u96fb\u8a71\u756a\u53f7<\/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>\u30e1\u30fc\u30eb\u30a2\u30c9\u30ec\u30b9<\/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>\u672c\u4eba\u3068\u306e\u95a2\u4fc2<\/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\">\u305d\u306e\u4ed6\u306e\u60c5\u5831 <\/span><span>\u4f53\u8abf\u3084\u6cbb\u7642\u306b\u95a2\u3057\u3066\u3001\u95a2\u9023\u304c\u3042\u308b\u3068\u601d\u308f\u308c\u308b\u8ffd\u52a0\u60c5\u5831\u3092\u8a18\u5165\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/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\">\u5f53\u9662\u3078\u306e\u3054\u5e0c\u671b\u30fb\u3054\u7d39\u4ecb\u5143<\/span><br \/>\n<span class=\"section required\">\u6cbb\u7642\u306b\u95a2\u3059\u308b\u3054\u5e0c\u671b\u3092\u304a\u805e\u304b\u305b\u304f\u3060\u3055\u3044\u3002<\/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=\"\u3059\u3050\u306b\u6cbb\u7642\u3057\u305f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u3059\u3050\u306b\u6cbb\u7642\u3057\u305f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"\u6765\u9662\u306e\u4e88\u7d04\u3092\u3057\u305f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u6765\u9662\u306e\u4e88\u7d04\u3092\u3057\u305f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"\u8a3a\u5bdf\u5185\u5bb9\u30fb\u6cbb\u7642\u65b9\u6cd5\u306b\u95a2\u3057\u3066\u77e5\u308a\u305f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u8a3a\u5bdf\u5185\u5bb9\u30fb\u6cbb\u7642\u65b9\u6cd5\u306b\u95a2\u3057\u3066\u77e5\u308a\u305f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"\u6599\u91d1\u30fb\u652f\u6255\u65b9\u6cd5\u306b\u3064\u3044\u3066\u77e5\u308a\u305f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u6599\u91d1\u30fb\u652f\u6255\u65b9\u6cd5\u306b\u3064\u3044\u3066\u77e5\u308a\u305f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"purpose-of-your-inquiry[]\" value=\"\u305d\u306e\u4ed6\u306b\u3064\u3044\u3066\u77e5\u308a\u305f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6\u306b\u3064\u3044\u3066\u77e5\u308a\u305f\u3044<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"section required\">\u3069\u306e\u3088\u3046\u306b\u5f53\u9662\u3092\u77e5\u308a\u307e\u3057\u305f\u304b\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=\"\u53cb\u4eba\u306e\u7d39\u4ecb\" \/><span class=\"wpcf7-list-item-label\">\u53cb\u4eba\u306e\u7d39\u4ecb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u30a8\u30fc\u30b8\u30a7\u30f3\u30c8\u306e\u7d39\u4ecb\" \/><span class=\"wpcf7-list-item-label\">\u30a8\u30fc\u30b8\u30a7\u30f3\u30c8\u306e\u7d39\u4ecb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u30bb\u30df\u30ca\u30fc\u53c2\u52a0\" \/><span class=\"wpcf7-list-item-label\">\u30bb\u30df\u30ca\u30fc\u53c2\u52a0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u30a6\u30a7\u30d6\u30b5\u30a4\u30c8\u3092\u898b\u305f\" \/><span class=\"wpcf7-list-item-label\">\u30a6\u30a7\u30d6\u30b5\u30a4\u30c8\u3092\u898b\u305f<\/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=\"WeChat\" \/><span class=\"wpcf7-list-item-label\">WeChat<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input 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