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["新生病院　診察前問診票"]
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["ご記入日",null,null,null,"平成",null,null,null,"年",null,null,null,"月",null,null,null,"日"]
["患者氏名",null,null,null,null,null,null,null,null,null,null,null,"記入者氏名",null,null,null,null,null,null,null,null,null,"（続柄",null,null,null,"）"]
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["A",null,"以下の質問にお答えください。（書き込むか該当箇所を選んで下さい。）"]
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["①今一番お困りの症状は何ですか？　（例：ゆううつ、物忘れ、不眠、不安感などC項参照）"]
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["②いつ頃からお困りですか？（可能であれば、その経過をご記入下さい。）"]
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["③今まで精神神経科（心療内科・神経内科・脳神経外科）に受診やご入院された"]
["　ことはありますか？"]
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[null,null,null,"（その時期と病名を教えて下さい）"]
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["④今までに大きな病気やけがをしたことがありますか？"]
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[null,null,null,"（病院名とその時期・病名を教えて下さい）"]
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["⑤精神科のご病気以外で現在飲んでいる薬はありますか？"]
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[null,null,null,"（病名とお薬のお名前を教えて下さい）"]
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["⑥現在、誰と暮らしていますか？（例：父４５歳、母４２歳、弟１６歳）"]
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[null,"ご兄弟姉妹のいる方は、何人兄弟姉妹の何番目かもご記入下さい。"]
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["⑦ ご結婚されていますか？",null,null,null,null,null,null,null,null,null,"→"]
["⑧ お仕事はされていますか？",null,null,null,null,null,null,null,null,null,"→",null,null,null,null,null,null,"（",null,null,null,null,null,null,null,"）"]
["⑨ 最終学歴は？",null,null,null,null,null,null,"→","（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["⑩ あなたは、ご自分自身をどのような性格だとおもっていますか？"]
[null,"↳","（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["⑪ 宗教を信仰していますか？",null,null,null,null,null,null,null,null,null,"→",null,null,null,null,null,null,"（",null,null,null,null,null,null,null,"）"]
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["B",null,"日常生活についてお聞きします。"]
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["・","身長：",null,null,null,"cm",null,"・","体重：",null,null,null,"kg",null,"・","利き手："]
["・","睡眠："]
["・","食欲："]
["・","便通："]
["・","生理：",null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,"歳ごろ）"]
["・","アレルギー：",null,null,null,null,null,null,null,null,null,"→","（",null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["・","タ バ コ    ：",null,null,null,null,null,null,null,null,null,"→","１日（",null,null,null,"）本"]
["・","アルコール："]
[null,null,null,null,null,null,null,null,"→何をどれくらい？",null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"※飲み方に問題があると自分で思いますか？また、周囲の人から問題があると指摘されたことはありますか？"]
[null,null,null,null,null,null,"（喧嘩・飲酒運転で検挙など具体的に：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
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["C",null,"今のご自身の状態をお聞きします。（当てはまるものを全て選んで下さい）"]
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[null,null,"誰もいないのに声が聞こえる。"]
[null,null,"何もないのにおかしなものが見える。"]
[null,null,"色々な音が気になる。（自分と関係あるように思えてしまう。）"]
[null,null,"人の視線が気になる。"]
[null,null,"見られている、監視されていると思う。"]
[null,null,"口、頭、手足など、体の様々な場所の感覚がおかしい。痛みに違和感がある。"]
[null,null,"他の診療科では異常がなく、精神科での受診を勧められた。"]
[null,null,"自分の周囲の人が信頼できない。怖い。（自分にとってマイナスの存在である。）"]
[null,null,"憂うつ気分が強い。"]
[null,null,"興味や喜びがなくなる。（世の中のニュースなどへの関心がない。）"]
[null,null,"意欲がない。"]
[null,null,"自分を責める。"]
[null,null,"死にたい。消えてなくなりたい。"]
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["D",null,"ご家族の方へお聞きします。"]
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["① 当院にご本人様を連れてこられた一番の理由はなんですか？"]
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["② 診察医に最も伝えたいご本人様の状態はどのようなものですか？"]
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["E",null,"利用されている制度についてお聞きします。"]
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["・","自立支援医療制度",null,null,null,null,null,null,"："]
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["・","精神障碍者保健福祉手帳",null,null,null,null,null,null,"：",null,null,null,null,null,null,null,null,"級"]
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["・","その他の障害者手帳",null,null,null,null,null,null,"：",null,null,null,null,null,null,null,null,null,null,"級",null,null,null,null,null,"級"]
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["・","障害者年金制度",null,null,null,null,null,null,"：",null,null,null,null,null,null,null,null,"級"]
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["・","介護保険制度",null,null,null,null,null,null,"："]
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["質問は以上になります。ありがとうございました。"]