{"id":9175,"date":"2026-02-25T00:00:49","date_gmt":"2026-02-24T15:00:49","guid":{"rendered":"https:\/\/mrclinic.tokyo\/jp\/?page_id=9175"},"modified":"2026-03-12T15:06:44","modified_gmt":"2026-03-12T06:06:44","slug":"cancer-treatment-questionnaire","status":"publish","type":"page","link":"https:\/\/mrclinic.tokyo\/jp\/cancer-treatment-questionnaire\/","title":{"rendered":"\u304c\u3093\u6cbb\u7642\u306b\u95a2\u3059\u308b\u554f\u8a3a\u7968"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9175\" class=\"elementor elementor-9175\">\n\t\t\t\t<div class=\"elementor-element elementor-element-661f19c8 e-flex e-con-boxed e-con e-parent\" data-id=\"661f19c8\" 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-608d991e e-con-full e-flex e-con e-child\" data-id=\"608d991e\" 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-792edb46 elementor-widget elementor-widget-spacer\" data-id=\"792edb46\" 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-26b0a7fd elementor-widget elementor-widget-heading\" data-id=\"26b0a7fd\" 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\">\u304c\u3093\u6cbb\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-63d351a3 elementor-widget elementor-widget-text-editor\" data-id=\"63d351a3\" 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\u304c\u3093\u6cbb\u7642\u3092\u3054\u5e0c\u671b\u306e\u65b9\u306f\u3001\u30b3\u30f3\u30b5\u30eb\u30c6\u30a3\u30f3\u30b0\u524d\u306b\u3053\u3061\u3089\u306e\u554f\u8a3a\u7968\u306b\u3054\u8a18\u5165\u3044\u305f\u3060\u304d\u3001\u9001\u4fe1\u3092\u304a\u9858\u3044\u3044\u305f\u3057\u307e\u3059\u3002\u4e8b\u524d\u306b\u60c5\u5831\u3092\u5171\u6709\u3044\u305f\u3060\u304f\u3053\u3068\u3067\u3001\u30d2\u30a2\u30ea\u30f3\u30b0\u306e\u6642\u9593\u3092\u77ed\u7e2e\u3057\u3001\u3088\u308a\u5145\u5b9f\u3057\u305f\u3001\u5b9f\u308a\u306e\u3042\u308b\u30b3\u30f3\u30b5\u30eb\u30c6\u30a3\u30f3\u30b0\u3092\u63d0\u4f9b\u3067\u304d\u308b\u3088\u3046\u306b\u306a\u308a\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-31b82b6 elementor-widget elementor-widget-text-editor\" data-id=\"31b82b6\" 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\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\n\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-4c2b4035 elementor-widget elementor-widget-spacer\" data-id=\"4c2b4035\" 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-24da925f elementor-widget elementor-widget-contact-form-7\" data-id=\"24da925f\" 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-f9174-o1\" lang=\"ja\" dir=\"ltr\" data-wpcf7-id=\"9174\">\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\/9175#wpcf7-f9174-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=\"9174\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"ja\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f9174-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\">\u5165\u529b\u65e5<\/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\u69d8\u60c5\u5831<\/span><br \/>\n<span class=\"required\">\u6c0f\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\">\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><br \/>\n<span>\u4f53\u91cd\uff1a\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 \u73fe\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 <\/span><span> (\u5dee <\/span><span><span class=\"wpcf7-form-control-wrap\" data-name=\"your-difference-weight\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number length2\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"your-difference-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-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\">\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\">\u304c\u3093\u306e\u75c5\u6b74<\/span><br \/>\n<span class=\"section required\">\u304c\u3093\u306e\u90e8\u4f4d<\/span> (\u8a72\u5f53\u3059\u308b\u3082\u306e\u3092\u3059\u3079\u3066\u30c1\u30a7\u30c3\u30af\u3057\u3066\u304f\u3060\u3055\u3044)<br \/>\n<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\u7acb\u817a\" \/><span class=\"wpcf7-list-item-label\">\u524d\u7acb\u817a<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u5927\u8178\" \/><span class=\"wpcf7-list-item-label\">\u5927\u8178<\/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\u81d3\" \/><span class=\"wpcf7-list-item-label\">\u809d\u81d3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u81b5\u81d3\" \/><span class=\"wpcf7-list-item-label\">\u81b5\u81d3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u76ae\u819a\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u819a<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-location[]\" value=\"\u8133\" \/><span class=\"wpcf7-list-item-label\">\u8133<\/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=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"section required\">\u30b9\u30c6\u30fc\u30b8<\/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;\u4ee5\u4e0b\u304b\u3089\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044&#8212;<\/option><option value=\"\u30b9\u30c6\u30fc\u30b8\uff10\">\u30b9\u30c6\u30fc\u30b8\uff10<\/option><option value=\"\u30b9\u30c6\u30fc\u30b8\u2160\">\u30b9\u30c6\u30fc\u30b8\u2160<\/option><option value=\"\u30b9\u30c6\u30fc\u30b8\u2161\">\u30b9\u30c6\u30fc\u30b8\u2161<\/option><option value=\"\u30b9\u30c6\u30fc\u30b8\u2162\">\u30b9\u30c6\u30fc\u30b8\u2162<\/option><option value=\"\u30b9\u30c6\u30fc\u30b8\u2163\">\u30b9\u30c6\u30fc\u30b8\u2163<\/option><option value=\"\u4e0d\u660e\">\u4e0d\u660e<\/option><\/select><\/span><\/span><br \/>\n<span class=\"section\">\u304c\u3093\u6cbb\u7642<\/span><span>\u53d7\u3051\u305f\u304c\u3093\u6cbb\u7642\u3092\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044\u3002<\/span><br \/>\n<span class=\"subsection required\">\u624b\u8853<\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-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=\"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> \u5e74<\/span><span class=\"rindent\">\u624b\u8853\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\u7642\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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u671f\u9593 (\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\u304b\u3089<\/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>\u85ac\u54c1\u540d <\/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=\"\u30a2\u30eb\u30ad\u30eb\u5316\u5264\" \/><span class=\"wpcf7-list-item-label\">\u30a2\u30eb\u30ad\u30eb\u5316\u5264<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u4ee3\u8b1d\u62ee\u6297\u85ac\" \/><span class=\"wpcf7-list-item-label\">\u4ee3\u8b1d\u62ee\u6297\u85ac<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u6297\u816b\u760d\u6297\u751f\u7269\u8cea\" \/><span class=\"wpcf7-list-item-label\">\u6297\u816b\u760d\u6297\u751f\u7269\u8cea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u30c8\u30dd\u30a4\u30bd\u30e1\u30e9\u30fc\u30bc\u963b\u5bb3\u85ac\" \/><span class=\"wpcf7-list-item-label\">\u30c8\u30dd\u30a4\u30bd\u30e1\u30e9\u30fc\u30bc\u963b\u5bb3\u85ac<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u6709\u7cf8\u5206\u88c2\u6291\u5236\u85ac\" \/><span class=\"wpcf7-list-item-label\">\u6709\u7cf8\u5206\u88c2\u6291\u5236\u85ac<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-medication[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u52b9\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;\u4ee5\u4e0b\u304b\u3089\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044&#8212;<\/option><option value=\"\u826f\u597d\">\u826f\u597d<\/option><option value=\"\u4e0d\u826f\">\u4e0d\u826f<\/option><option value=\"\u5909\u5316\u306a\u3057\">\u5909\u5316\u306a\u3057<\/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=\"\u5614\u5410\/\u5410\u304d\u6c17\" \/><span class=\"wpcf7-list-item-label\">\u5614\u5410\/\u5410\u304d\u6c17<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u8131\u6bdb\" \/><span class=\"wpcf7-list-item-label\">\u8131\u6bdb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u4f53\u91cd\u6e1b\u5c11\" \/><span class=\"wpcf7-list-item-label\">\u4f53\u91cd\u6e1b\u5c11<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u4e0b\u75e2\" \/><span class=\"wpcf7-list-item-label\">\u4e0b\u75e2<\/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=\"\u3057\u3073\u308c\" \/><span class=\"wpcf7-list-item-label\">\u3057\u3073\u308c<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u8ca7\u8840\" \/><span class=\"wpcf7-list-item-label\">\u8ca7\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\u5185\u708e\" \/><span class=\"wpcf7-list-item-label\">\u53e3\u5185\u708e<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u76ae\u819a\u75be\u60a3\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u819a\u75be\u60a3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u722a\u306e\u5909\u5316\" \/><span class=\"wpcf7-list-item-label\">\u722a\u306e\u5909\u5316<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-chemotherapy-sideeffects[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">\u653e\u5c04\u7dda\u6cbb\u7642 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u653e\u5c04\u7dda\u6cbb\u7642\u306e\u7a2e\u985e <\/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=\"\u96fb\u5b50\u7dda\" \/><span class=\"wpcf7-list-item-label\">\u96fb\u5b50\u7dda<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"X\u7dda\uff08IMRT\/IGRT\uff09\" \/><span class=\"wpcf7-list-item-label\">X\u7dda\uff08IMRT\/IGRT\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u30b5\u30a4\u30d0\u30fc\u30ca\u30a4\u30d5\" \/><span class=\"wpcf7-list-item-label\">\u30b5\u30a4\u30d0\u30fc\u30ca\u30a4\u30d5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u30ac\u30f3\u30de\u30ca\u30a4\u30d5\" \/><span class=\"wpcf7-list-item-label\">\u30ac\u30f3\u30de\u30ca\u30a4\u30d5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u967d\u5b50\u7dda\" \/><span class=\"wpcf7-list-item-label\">\u967d\u5b50\u7dda<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u91cd\u7c92\u5b50\u7dda\" \/><span class=\"wpcf7-list-item-label\">\u91cd\u7c92\u5b50\u7dda<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-type[]\" value=\"\u7d44\u7e54\u5185\u7167\u5c04\" \/><span class=\"wpcf7-list-item-label\">\u7d44\u7e54\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\u7642\u6cd5\" \/><span class=\"wpcf7-list-item-label\">\u5185\u7528\u7642\u6cd5<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u671f\u9593 (\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\u304b\u3089<\/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>\u6cbb\u7642\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\u7642\u52b9\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;\u4ee5\u4e0b\u304b\u3089\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044&#8212;<\/option><option value=\"\u826f\u597d\">\u826f\u597d<\/option><option value=\"\u4e0d\u826f\">\u4e0d\u826f<\/option><option value=\"\u5909\u5316\u306a\u3057\">\u5909\u5316\u306a\u3057<\/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=\"\u5614\u6c17\" \/><span class=\"wpcf7-list-item-label\">\u5614\u6c17<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u8131\u6bdb\" \/><span class=\"wpcf7-list-item-label\">\u8131\u6bdb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u4e0b\u75e2\" \/><span class=\"wpcf7-list-item-label\">\u4e0b\u75e2<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u53e3\u5185\u708e\" \/><span class=\"wpcf7-list-item-label\">\u53e3\u5185\u708e<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u53e3\u8154\u4e7e\u71e5\" \/><span class=\"wpcf7-list-item-label\">\u53e3\u8154\u4e7e\u71e5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u5473\u899a\u969c\u5bb3\" \/><span class=\"wpcf7-list-item-label\">\u5473\u899a\u969c\u5bb3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u98df\u4e8b\u306e\u3064\u304b\u3048(\u98df\u9053\u708e)\" \/><span class=\"wpcf7-list-item-label\">\u98df\u4e8b\u306e\u3064\u304b\u3048(\u98df\u9053\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\u819a\u306e\u767a\u8d64\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u819a\u306e\u767a\u8d64<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u76ae\u819a\u306e\u76ae\u3080\u3051\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u819a\u306e\u76ae\u3080\u3051<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u76ae\u819a\u708e(\u65e5\u713c\u3051\u306e\u3088\u3046\u306a)\" \/><span class=\"wpcf7-list-item-label\">\u76ae\u819a\u708e(\u65e5\u713c\u3051\u306e\u3088\u3046\u306a)<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-radiotherapy-sideeffects[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">\u514d\u75ab\u6cbb\u7642 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy\" value=\"\u3044\u3044\u3048\" \/><span class=\"wpcf7-list-item-label\">\u3044\u3044\u3048<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u514d\u75ab\u7642\u6cd5\u306e\u7a2e\u985e <\/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(\u6a39\u72b6\u7d30\u80de)\" \/><span class=\"wpcf7-list-item-label\">DC(\u6a39\u72b6\u7d30\u80de)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"\u6d3b\u6027\u5316\u30ea\u30f3\u30d1\u7403\" \/><span class=\"wpcf7-list-item-label\">\u6d3b\u6027\u5316\u30ea\u30f3\u30d1\u7403<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-type[]\" value=\"\u304c\u3093\u30ef\u30af\u30c1\u30f3\" \/><span class=\"wpcf7-list-item-label\">\u304c\u3093\u30ef\u30af\u30c1\u30f3<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u671f\u9593 (\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\u304b\u3089<\/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\u30c1\u30a7\u30c3\u30af\u30dd\u30a4\u30f3\u30c8\u963b\u5bb3\u85ac<\/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=\"\u30aa\u30d7\u30b7\u30fc\u30dc\" \/><span class=\"wpcf7-list-item-label\">\u30aa\u30d7\u30b7\u30fc\u30dc<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u30ad\u30a4\u30c8\u30eb\u30fc\u30c0\" \/><span class=\"wpcf7-list-item-label\">\u30ad\u30a4\u30c8\u30eb\u30fc\u30c0<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u30e4\u30fc\u30dc\u30a4\" \/><span class=\"wpcf7-list-item-label\">\u30e4\u30fc\u30dc\u30a4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u30a4\u30df\u30d5\u30a3\u30f3\u30b8\" \/><span class=\"wpcf7-list-item-label\">\u30a4\u30df\u30d5\u30a3\u30f3\u30b8<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u30c6\u30bb\u30f3\u30c8\u30ea\u30af\" \/><span class=\"wpcf7-list-item-label\">\u30c6\u30bb\u30f3\u30c8\u30ea\u30af<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-immunotherapy-immunecheckpointinhabitors[]\" value=\"\u30d0\u30d9\u30f3\u30c1\u30aa\" \/><span class=\"wpcf7-list-item-label\">\u30d0\u30d9\u30f3\u30c1\u30aa<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection required\">\u670d\u7528\u4e2d\u306e\u304c\u3093\u6cbb\u7642\u85ac <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications\" 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=\"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=\"\u30b7\u30b9\u30d7\u30e9\u30c1\u30f3\" \/><span class=\"wpcf7-list-item-label\">\u30b7\u30b9\u30d7\u30e9\u30c1\u30f3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u30c9\u30ad\u30bd\u30eb\u30d3\u30b7\u30f3\" \/><span class=\"wpcf7-list-item-label\">\u30c9\u30ad\u30bd\u30eb\u30d3\u30b7\u30f3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u30c8\u30e9\u30b9\u30c4\u30ba\u30de\u30d6 (\u30cf\u30fc\u30bb\u30d7\u30c1\u30f3)\" \/><span class=\"wpcf7-list-item-label\">\u30c8\u30e9\u30b9\u30c4\u30ba\u30de\u30d6 (\u30cf\u30fc\u30bb\u30d7\u30c1\u30f3)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u30cb\u30dc\u30eb\u30de\u30d6 (\u30aa\u30d7\u30b8\u30fc\u30dc)\" \/><span class=\"wpcf7-list-item-label\">\u30cb\u30dc\u30eb\u30de\u30d6 (\u30aa\u30d7\u30b8\u30fc\u30dc)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u30bf\u30e2\u30ad\u30b7\u30d5\u30a7\u30f3\" \/><span class=\"wpcf7-list-item-label\">\u30bf\u30e2\u30ad\u30b7\u30d5\u30a7\u30f3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u30e9\u30d1\u30c1\u30cb\u30d6\" \/><span class=\"wpcf7-list-item-label\">\u30e9\u30d1\u30c1\u30cb\u30d6<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-current-cancer-medications-type[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"subsection\">\u305d\u306e\u4ed6\u306e\u670d\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\u542b\u3081\u3066\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=\"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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-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=\"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\u30b5\u30e9\u30b5\u30e9\u30b5\u30d7\u30ea\u30e1\u30f3\u30c8 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-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=\"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\u5727 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-hypertension\" 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=\"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 <\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-diabetes\" 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=\"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\u8cea\u7570\u5e38\u75c7\/\u9ad8\u8102\u8840\u75c7\/\u30b3\u30ec\u30b9\u30c6\u30ed\u30fc\u30eb<\/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=\"\u306f\u3044\" \/><span class=\"wpcf7-list-item-label\">\u306f\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-dyslipidemia\" 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=\"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>\u305d\u306e\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\">\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=\"\u3042\u308a\" \/><span class=\"wpcf7-list-item-label\">\u3042\u308a<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"data-from-other-hospitals\" value=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/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=\"\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><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\uff1a<\/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=\"section required\">\u8ee2\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=\"\u3042\u308a\" \/><span class=\"wpcf7-list-item-label\">\u3042\u308a<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-metastasis\" value=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u8ee2\u79fb\u5148\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\u8a55\u4fa1<\/span><br \/>\n<span class=\"subsection required\">\u75db\u307f\u306e\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=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-location[]\" value=\"\u80f8\" \/><span class=\"wpcf7-list-item-label\">\u80f8<\/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\u4e2d\" \/><span class=\"wpcf7-list-item-label\">\u80cc\u4e2d<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-location[]\" value=\"\u95a2\u7bc0\" \/><span class=\"wpcf7-list-item-label\">\u95a2\u7bc0<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-location[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u75db\u307f\u306e\u5f37\u3055\u30921\u304b\u308910\u306e\u30b9\u30b1\u30fc\u30eb\u3067\u304a\u805e\u304b\u305b\u304f\u3060\u3055\u3044\u3002<\/span><br \/>\n<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;\u4ee5\u4e0b\u304b\u3089\u9078\u629e\u3057\u3066\u304f\u3060\u3055\u3044&#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=\u5168\u304f\u75db\u307f\u304c\u306a\u3044\u300110=\u8010\u3048\u96e3\u3044\u307b\u3069\u306e\u75db\u307f) <\/span><br \/>\n<span class=\"subsection\">\u75db\u307f\u306e\u7a2e\u985e <\/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=\"\u92ed\u3044\" \/><span class=\"wpcf7-list-item-label\">\u92ed\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-type[]\" value=\"\u920d\u3044\" \/><span class=\"wpcf7-list-item-label\">\u920d\u3044<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-type[]\" value=\"\u30ba\u30ad\u30ba\u30ad\u3059\u308b\" \/><span class=\"wpcf7-list-item-label\">\u30ba\u30ad\u30ba\u30ad\u3059\u308b<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-type[]\" value=\"\u713c\u3051\u308b\u3088\u3046\u306a\" \/><span class=\"wpcf7-list-item-label\">\u713c\u3051\u308b\u3088\u3046\u306a<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-type[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection\">\u75db\u307f\u306e\u6301\u7d9a\u6642\u9593\u3068\u983b\u5ea6 <\/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=\"\u5e38\u306b\" \/><span class=\"wpcf7-list-item-label\">\u5e38\u306b<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-frequency[]\" value=\"\u3068\u304d\u3069\u304d\" \/><span class=\"wpcf7-list-item-label\">\u3068\u304d\u3069\u304d<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-frequency[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"subsection required\">\u75db\u307f\u306e\u7de9\u548c\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=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-anyrelief-measures[]\" value=\"NSAIDS\" \/><span class=\"wpcf7-list-item-label\">NSAIDS<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-anyrelief-measures[]\" value=\"\u30d1\u30e9\u30bb\u30bf\u30e2\u30fc\u30eb\" \/><span class=\"wpcf7-list-item-label\">\u30d1\u30e9\u30bb\u30bf\u30e2\u30fc\u30eb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-anyrelief-measures[]\" value=\"\u9ebb\u85ac\" \/><span class=\"wpcf7-list-item-label\">\u9ebb\u85ac<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cancer-history-pain-assessment-anyrelief-measures[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/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 required\">\u904e\u53bb\u306e\u75c5\u6b74 <\/span> (\u904e\u53bb\u306b\u304b\u304b\u3063\u305f\u75c5\u6b74\u306e\u3042\u308b\u75be\u60a3\u306b\u30c1\u30a7\u30c3\u30af\u3092\u3057\u3066\u304f\u3060\u3055\u3044)<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=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u8ca7\u8840\" \/><span class=\"wpcf7-list-item-label\">\u8ca7\u8840<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u4e0d\u5b89\u75c7\" \/><span class=\"wpcf7-list-item-label\">\u4e0d\u5b89\u75c7<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u95a2\u7bc0\u708e\" \/><span class=\"wpcf7-list-item-label\">\u95a2\u7bc0\u708e<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u5598\u606f\" \/><span class=\"wpcf7-list-item-label\">\u5598\u606f<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u30a2\u30ec\u30eb\u30ae\u30fc\" \/><span class=\"wpcf7-list-item-label\">\u30a2\u30ec\u30eb\u30ae\u30fc<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u8840\u6db2\u51dd\u56fa\u969c\u5bb3\" \/><span class=\"wpcf7-list-item-label\">\u8840\u6db2\u51dd\u56fa\u969c\u5bb3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u982d\u75db\" \/><span class=\"wpcf7-list-item-label\">\u982d\u75db<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" 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=\"medical-history[]\" 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=\"medical-history[]\" value=\"\u9aa8\u7c97\u3057\u3087\u3046\u75c7\" \/><span class=\"wpcf7-list-item-label\">\u9aa8\u7c97\u3057\u3087\u3046\u75c7<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u767a\u4f5c\uff08\u3051\u3044\u308c\u3093\u3092\u542b\u3080\uff09\" \/><span class=\"wpcf7-list-item-label\">\u767a\u4f5c\uff08\u3051\u3044\u308c\u3093\u3092\u542b\u3080\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u8133\u5352\u4e2d\" \/><span class=\"wpcf7-list-item-label\">\u8133\u5352\u4e2d<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"HIV\/AIDS\uff08\u30a8\u30a4\u30ba\uff09\" \/><span class=\"wpcf7-list-item-label\">HIV\/AIDS\uff08\u30a8\u30a4\u30ba\uff09<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u7532\u72b6\u817a\u6a5f\u80fd\u4f4e\u4e0b\u75c7\" \/><span class=\"wpcf7-list-item-label\">\u7532\u72b6\u817a\u6a5f\u80fd\u4f4e\u4e0b\u75c7<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" 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=\"medical-history[]\" value=\"\u9ad8\u8102\u8840\u75c7\uff08\u9ad8\u30b3\u30ec\u30b9\u30c6\u30ed\u30fc\u30eb\uff09\" \/><span class=\"wpcf7-list-item-label\">\u9ad8\u8102\u8840\u75c7\uff08\u9ad8\u30b3\u30ec\u30b9\u30c6\u30ed\u30fc\u30eb\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\u75be\u60a3\" \/><span class=\"wpcf7-list-item-label\">\u5fc3\u75be\u60a3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u7d50\u6838\" \/><span class=\"wpcf7-list-item-label\">\u7d50\u6838<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u6f70\u760d\" \/><span class=\"wpcf7-list-item-label\">\u6f70\u760d<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"medical-history[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><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=\"part\">\u65e5\u5e38\u751f\u6d3b\u52d5\u4f5c\u306e\u8a55\u4fa1<\/span><br \/>\n<span class=\"section required\">\u79fb\u52d5\u6a5f\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=\"\u81ea\u7acb\u3057\u3066\u884c\u3048\u308b\" \/><span class=\"wpcf7-list-item-label\">\u81ea\u7acb\u3057\u3066\u884c\u3048\u308b<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"daily-living-activities-mobility\" value=\"\u81ea\u7acb\u3057\u3066\u884c\u3048\u306a\u3044\" \/><span class=\"wpcf7-list-item-label\">\u81ea\u7acb\u3057\u3066\u884c\u3048\u306a\u3044<\/span><\/label><\/span><\/span><\/span><\/span><span>\u300c\u81ea\u7acb\u3057\u3066\u884c\u3048\u306a\u3044\u300d\u3092\u9078\u629e\u3055\u308c\u305f\u5834\u5408\u3001\u5177\u4f53\u7684\u306a\u7a2e\u985e\u3092\u6559\u3048\u3066\u304f\u3060\u3055\u3044\u3002<\/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=\"\u6b69\u884c\u5668\" \/><span class=\"wpcf7-list-item-label\">\u6b69\u884c\u5668<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"daily-living-activities-mobility-no[]\" value=\"\u8eca\u3044\u3059\" \/><span class=\"wpcf7-list-item-label\">\u8eca\u3044\u3059<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"daily-living-activities-mobility-no[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span class=\"section required\">\u30ab\u30c6\u30fc\u30c6\u30eb\u306e\u4f7f\u7528 <\/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=\"\u3042\u308a\" \/><span class=\"wpcf7-list-item-label\">\u3042\u308a<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"daily-living-activities-catheter\" value=\"\u306a\u3057\" \/><span class=\"wpcf7-list-item-label\">\u306a\u3057<\/span><\/label><\/span><\/span><\/span><\/span><span>\u300c\u3042\u308a\u300d\u3092\u9078\u629e\u3055\u308c\u305f\u5834\u5408\u3001\u7a2e\u985e\u3092\u6559\u3048\u3066\u304f\u3060\u3055\u3044\u3002<\/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\u30ab\u30c6\u30fc\u30c6\u30eb\" \/><span class=\"wpcf7-list-item-label\">\u5c3f\u9053\u30ab\u30c6\u30fc\u30c6\u30eb<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"daily-living-activities-catheter-yes[]\" value=\"\u7d4c\u7ba1\u6804\u990a\u30c1\u30e5\u30fc\u30d6\" \/><span class=\"wpcf7-list-item-label\">\u7d4c\u7ba1\u6804\u990a\u30c1\u30e5\u30fc\u30d6<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"daily-living-activities-catheter-yes[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span>\n\t<\/p>\n\t<p><span class=\"part\">\u3054\u5bb6\u65cf\u306e\u304c\u3093\u75c5\u6b74<\/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\u89aa\" \/><span class=\"wpcf7-list-item-label\">\u7236\u89aa<\/span><\/label><\/span><\/span><\/span><\/span><span>\u304c\u3093\u306e\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\u89aa\" \/><span class=\"wpcf7-list-item-label\">\u6bcd\u89aa<\/span><\/label><\/span><\/span><\/span><\/span><span>\u304c\u3093\u306e\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>\u304c\u3093\u306e\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>\u304c\u3093\u306e\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=\"\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=\"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\">\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 type=\"checkbox\" name=\"how-about-our-clinic[]\" value=\"\u305d\u306e\u4ed6\" \/><span class=\"wpcf7-list-item-label\">\u305d\u306e\u4ed6<\/span><\/label><\/span><\/span><\/span><\/span><br \/>\n<span>\u7d39\u4ecb\u3044\u305f\u3060\u3044\u305f\u3054\u53cb\u4eba\u3001\u30a8\u30fc\u30b8\u30a7\u30f3\u30c8\u3001\u305d\u306e\u4ed6\u3092\u9078\u629e\u3057\u305f\u5834\u5408\u306f\u3001\u30af\u30ea\u30cb\u30c3\u30af\u3092\u77e5\u3063\u305f\u304d\u3063\u304b\u3051\u3092\u3054\u8a18\u5165\u304f\u3060\u3055\u3044\u3002<\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"how-about-our-clinic-other\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"how-about-our-clinic-other\"><\/textarea><\/span><br \/>\n\u3054\u5354\u529b\u3044\u305f\u3060\u304d\u3001\u3042\u308a\u304c\u3068\u3046\u3054\u3056\u3044\u307e\u3057\u305f\u3002<br \/>\n<div class=\"cf7-cf-turnstile\" style=\"margin-top: 0px; margin-bottom: -15px;\"> <div id=\"cf-turnstile-cf7-3919022143\" class=\"cf-turnstile\" data-sitekey=\"0x4AAAAAABt3Vg0gFQYhOIjf\" data-theme=\"auto\" data-language=\"auto\" data-size=\"normal\" data-retry=\"auto\" data-retry-interval=\"1000\" data-refresh-expired=\"auto\" data-refresh-timeout=\"auto\" data-action=\"contact-form-7\" data-callback=\"turnstileCF7Callback\" data-appearance=\"always\"><\/div> <script>document.addEventListener(\"DOMContentLoaded\", function() { setTimeout(function(){ var e=document.getElementById(\"cf-turnstile-cf7-3919022143\"); if(e&&!e.innerHTML.trim()){turnstile.render(e, {sitekey:\"0x4AAAAAABt3Vg0gFQYhOIjf\"});} }, 200); });<\/script> <br class=\"cf-turnstile-br cf-turnstile-br-cf7-3919022143\"> <style>#cf-turnstile-cf7-3919022143 { margin-left: -15px; }<\/style> <script>document.addEventListener(\"DOMContentLoaded\",function(){document.querySelectorAll('.wpcf7-form').forEach(function(e){e.addEventListener('submit',function(){if(document.getElementById('cf-turnstile-cf7-3919022143')){setTimeout(function(){turnstile.reset('#cf-turnstile-cf7-3919022143');},1000)}})})});<\/script> <\/div><br\/><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"\u9001\u3000\u4fe1\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>\u304c\u3093\u6cbb\u7642\u306b\u95a2\u3059\u308b\u554f\u8a3a\u7968 \u304c\u3093\u6cbb\u7642\u3092\u3054\u5e0c\u671b\u306e\u65b9\u306f\u3001\u30b3\u30f3\u30b5\u30eb\u30c6\u30a3\u30f3\u30b0\u524d\u306b\u3053\u3061\u3089\u306e\u554f\u8a3a\u7968\u306b\u3054\u8a18\u5165\u3044\u305f\u3060\u304d\u3001\u9001\u4fe1\u3092\u304a\u9858\u3044\u3044\u305f\u3057\u307e\u3059\u3002\u4e8b\u524d\u306b\u60c5\u5831\u3092\u5171\u6709\u3044\u305f\u3060\u304f\u3053\u3068\u3067\u3001\u30d2\u30a2\u30ea\u30f3\u30b0\u306e\u6642\u9593\u3092\u77ed\u7e2e\u3057\u3001\u3088\u308a\u5145\u5b9f\u3057\u305f\u3001\u5b9f\u308a\u306e\u3042\u308b\u30b3\u30f3\u30b5\u30eb\u30c6\u30a3\u30f3 [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-9175","page","type-page","status-publish","hentry","no-thumb"],"_links":{"self":[{"href":"https:\/\/mrclinic.tokyo\/jp\/wp-json\/wp\/v2\/pages\/9175","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/mrclinic.tokyo\/jp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/mrclinic.tokyo\/jp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/mrclinic.tokyo\/jp\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/mrclinic.tokyo\/jp\/wp-json\/wp\/v2\/comments?post=9175"}],"version-history":[{"count":11,"href":"https:\/\/mrclinic.tokyo\/jp\/wp-json\/wp\/v2\/pages\/9175\/revisions"}],"predecessor-version":[{"id":9733,"href":"https:\/\/mrclinic.tokyo\/jp\/wp-json\/wp\/v2\/pages\/9175\/revisions\/9733"}],"wp:attachment":[{"href":"https:\/\/mrclinic.tokyo\/jp\/wp-json\/wp\/v2\/media?parent=9175"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}