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[]
[]
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[]
[null,"施術証明欄",null,null,null,"上記の通り施術を行い、その費用を領収しました。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"保健所登録区分"]
[]
[null,null,null,null,null,"療養費の受領を下記代理人に委任します。"]
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[]
[null,null,null,null,null,null,"    登録記号番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"名　称",null,null,null,null,{"$f":"基本!I6","v":"福岡鍼灸院"}]
[null,null,null,{"$f":"基本!C10","v":"40000141-0-0"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"施術管理者",null,null,null,null,null,null,null,"氏　名",null,null,null,null,{"$f":"基本!C5","v":"福岡太郎"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話",null,null,null,{"$f":"基本!C7","v":"092-123-4567"}]
[null,"申　請　欄"]
[null,null,null,null,null,"　上記の療養に要した費用に関して、療養費の支給を申請します。"]
[]
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[]
[null,null,null,null,null,{"$f":"IF(INDEX(データ記入,$CK$10,48)=\"\",\"\",INDEX(データ記入,$CK$10,48)) &\"長 殿\"","v":"福岡県後期高齢者医療広域連合長 殿"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（被保険者）",null,null,null,null,null,null,null,"氏　名",null,null,null,null,{"$f":"IF(INDEX(データ記入,$CK$10,10)=\"\",\"\",INDEX(データ記入,$CK$10,10))","v":"鈴木花子"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話",null,null,null,{"$f":"IF(INDEX(データ記入,$CK$10,50)=\"\",\"\",INDEX(データ記入,$CK$10,50))","v":"092-137-1787"}]
[]
[null,"支払機関欄",null,null,null,null,"支払区分",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"預金の種類",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"金融機関名"]
[]
[null,null,null,null,null,null,"1．振　   込",null,null,null,null,null,null,null,null,null,null,"2．銀行送金",null,null,null,null,null,null,null,null,null,null,null,null,null,"1．普通",null,null,null,null,null,null,null,"3．当座",null,null,null,null,null,null,null,null,null,null,"福岡銀行　本店営業部"]
[]
[null,null,null,null,null,null,"3．郵便局送金",null,null,null,null,null,null,null,null,null,null,"4．当 地 払",null,null,null,null,null,null,null,null,null,null,null,null,null,"2．通知",null,null,null,null,null,null,null,"4．別段"]
[]
[null,null,null,null,null,"口  座  名  義",null,null,null,null,null,null,null,null,null,{"$f":"基本!C29","v":"シャ）フクオカケンシンキュウマッサージシカイ"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"口座番号",null,null,null,null,null,null,null,"6",null,null,"6",null,null,"3",null,null,"7",null,null,"1",null,null,"1",null,null,"3",null,null,{"$f":"\"郵便局\" & \" \"","v":"郵便局 "}]
[]
[null,null,null,null,null,"カタカナで記入"]
[]
[null,"同意記録",null,null,null,"同意医師の氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住　　　　　所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"同意 年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"傷　病　名",null,null,null,null,null,null,null,null,null,null,null,null,"要加療期間"]
[]
[null,null,null,{"$f":"IF(INDEX(データ記入,$CK$10,44)=\"\",\"\",INDEX(データ記入,$CK$10,44))","v":"中村次郎"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(INDEX(データ記入,$CK$10,43)=\"\",\"\",INDEX(データ記入,$CK$10,43))","v":"福岡市中央区天神2-3-1"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(INDEX(データ記入,$CK$10,21)=\"\",\"\",INDEX(データ記入,$CK$10,21))","v":"脳梗塞（左片麻痺）"}]
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[]
[]
[]
[null,null,"本申請書に基づく給付金に関する受領を代理人に委任します。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"AH1","v":"令和"},null,null,null,{"$f":"AM1","v":5},null,null,null,"年",null,{"$f":"AR1","v":6},null,null,null,"月",null,{"$f":"X60","v":30},null,null,null,"日"]
[]
[null,null,null,null,"申請者",null,null,null,null,null,null,null,null,"住所",null,null,null,null,null,{"$f":"AR68","v":"福岡市博多区博多駅前3-1"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"代理人",null,null,null,null,null,null,"住所",null,null,null,null,null,{"$f":"基本!C23","v":"福岡市博多区博多駅前4丁目5-12"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"基本!C24","v":"公益社団法人福岡県鍼灸マッサージ師会"}]
[null,null,null,null,"（被保険者）",null,null,null,null,null,null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"氏名",null,null,null,null,null,{"$f":"基本!C25","v":"会長　古賀 慶之助"}]
[]
[]
[]
[]
[null,null,"※　この給付金の受療の代理人への委任は、受領委任の取扱規定（平成30年6月12日保発0612第2号通知）に従い行われるものです。"]
[null,null,"※　給付金に関する受領を代理人に委任する（申請者名義以外の口座に振込を希望される）場合に記入してください。"]
[null,null,"※　ただし、当該患者より依頼を受けた場合や当該患者が記入することができないやむを得ない理由がある場合は、"]
[null,null,null,null," 施術管理者等が代理をし当該患者から押印を受けてください。"]

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[]
[null,"施術者データ",null,null,null,null,null,null,"　白ヌキのセルは自分で入力してください"]
[null,"施術者氏名","福岡太郎"]
[null,"施術者住所","福岡県福岡市博多駅2丁目12-3",null,null,null,null,"院名","福岡鍼灸院"]
[null,"施術者電話","092-123-4567"]
[null,"中央団体施術者登録番号","400010019577AV",null,null,{"$f":"LEN(C8)","v":14}]
[null,"福岡広域連合登録NO","4081600477"]
[null,"受領委任登録記号番号","40000141-0-0",null,null,{"$f":"LEN(C10)","v":12}]
[null,"機関コード"]
[]
[null,"マッサージ（1局所につき）",null,null,350,null,null,null,"令和4年6月1日施術分より料金改定　　初検料1術1,780円　初検料2術1,860円  1術1,550円  2術1,610円　電療料34円　往療料4ｋｍまで2,300円、4km超2700円。マッサージ1局所350円、温罨法125円、電気光線器具160円、徒手矯正術790円、往療料4km2,300円、4km超2,550円）　施術報告書交付料480円　"]
[null,"変型徒手矯正施術（1肢につき）",null,null,450]
[null,"温罨法（1回につき）",null,null,125]
[null,"温罨法・電気光線器具",null,null,160]
[]
[null,"　　往療　４ｋｍ　まで",null,null,2300]
[null,"　　往療　４ｋｍ　超",null,null,2550]
[null,"施術報告書交付料",null,null,480]
[]
[]
[null,"代理人住所","福岡市博多区博多駅前4丁目5-12"]
[null,"代理人氏名","公益社団法人福岡県鍼灸マッサージ師会"]
[null,"代理人氏名","会長　古賀 慶之助"]
[null,"銀行名","福岡銀行"]
[null,"支店名","本店営業部"]
[null,"口座番号","6637113"]
[null,"口座名義人フリガナ","シャ）フクオカケンシンキュウマッサージシカイ"]

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[null,12,"１２月",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,651)=\"\",\"\",INDEX(データ記入,$FU$5,651))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,652)=\"\",\"\",INDEX(データ記入,$FU$5,652))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,653)=\"\",\"\",INDEX(データ記入,$FU$5,653))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,654)=\"\",\"\",INDEX(データ記入,$FU$5,654))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,655)=\"\",\"\",INDEX(データ記入,$FU$5,655))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,656)=\"\",\"\",INDEX(データ記入,$FU$5,656))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,657)=\"\",\"\",INDEX(データ記入,$FU$5,657))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,658)=\"\",\"\",INDEX(データ記入,$FU$5,658))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,659)=\"\",\"\",INDEX(データ記入,$FU$5,659))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,660)=\"\",\"\",INDEX(データ記入,$FU$5,660))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,661)=\"\",\"\",INDEX(データ記入,$FU$5,661))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,662)=\"\",\"\",INDEX(データ記入,$FU$5,662))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,663)=\"\",\"\",INDEX(データ記入,$FU$5,663))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,664)=\"\",\"\",INDEX(データ記入,$FU$5,664))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,665)=\"\",\"\",INDEX(データ記入,$FU$5,665))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,666)=\"\",\"\",INDEX(データ記入,$FU$5,666))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,667)=\"\",\"\",INDEX(データ記入,$FU$5,667))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,668)=\"\",\"\",INDEX(データ記入,$FU$5,668))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,669)=\"\",\"\",INDEX(データ記入,$FU$5,669))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,670)=\"\",\"\",INDEX(データ記入,$FU$5,670))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,671)=\"\",\"\",INDEX(データ記入,$FU$5,671))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,672)=\"\",\"\",INDEX(データ記入,$FU$5,672))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,673)=\"\",\"\",INDEX(データ記入,$FU$5,673))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,674)=\"\",\"\",INDEX(データ記入,$FU$5,674))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,675)=\"\",\"\",INDEX(データ記入,$FU$5,675))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,676)=\"\",\"\",INDEX(データ記入,$FU$5,676))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,677)=\"\",\"\",INDEX(データ記入,$FU$5,677))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,678)=\"\",\"\",INDEX(データ記入,$FU$5,678))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,679)=\"\",\"\",INDEX(データ記入,$FU$5,679))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,680)=\"\",\"\",INDEX(データ記入,$FU$5,680))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,681)=\"\",\"\",INDEX(データ記入,$FU$5,681))","v":""},null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,649)=\"\",\"\",INDEX(データ記入,$FU$5,649))","v":""},null,null,null,null,null,null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,650)=\"\",\"\",INDEX(データ記入,$FU$5,650))","v":""}]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,27)=\"\",\"\",INDEX(データ記入,$FU$5,27))","v":"歩行困難"}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,13)=\"\",\"\",INDEX(データ記入,$FU$5,13))","v":"要介護３．少し歩けるが、よろよろと歩行が安定しない。キツイキツイと連呼する。"}]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(INDEX(データ記入,$FU$5,11)=\"\",\"\",INDEX(データ記入,$FU$5,11))","v":"ベッドにしばらく座れるようになってきた。\r\n左手の筋拘縮がマッサージ後はかなり改善された。"}]

{"sheet":"16回以上理由","index":4,"n_rows":34,"n_cols":27,"rows_kept":34,"cut":false,"hidden":false,"merged":[[1,1,2,20],[1,21,1,26],[2,21,2,26],[3,0,5,0],[3,1,4,6],[3,7,3,9],[3,10,3,26],[4,7,4,9],[4,10,4,26],[5,1,5,6],[5,7,5,26],[8,0,12,0],[8,1,8,6],[8,7,8,26],[9,1,9,6],[9,7,9,26],[12,1,12,6],[12,7,12,26],[6,1,6,6],[6,7,6,26],[7,1,7,6],[7,7,7,26],[10,1,11,6],[10,7,10,26],[11,7,11,10],[11,11,11,14],[11,15,11,18],[11,19,11,22],[11,23,11,26],[13,1,13,13],[13,14,13,16],[13,17,13,26],[23,1,26,26],[16,2,16,6],[16,7,16,26],[17,2,17,6],[17,7,17,26],[18,2,18,6],[18,7,18,26],[14,1,18,1],[14,2,14,6],[14,7,14,26],[15,2,15,6],[15,7,15,26],[19,1,19,6],[19,7,19,26],[20,1,20,26],[21,2,21,26],[22,1,22,26],[33,1,33,26],[27,1,27,26],[28,1,28,26],[29,1,29,26],[30,1,30,26],[31,1,31,26],[32,1,32,26]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"別添２（別紙５）"]
[null,"１年以上・月１６回以上施術継続理由・状態記入書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（マッサージ用）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（   　　年　　月分）"]
["患　　　者","患者",null,null,null,null,null,"氏名"]
[null,null,null,null,null,null,null,"生年月日",null,null,"明 ・ 大 ・ 昭 ・ 平 ・ 令　　　年　　　月　　　日"]
[null,"傷病名"]
[null,"症状",null,null,null,null,null,"１．筋麻痺　 ２．関節拘縮 　３．その他（　　　　　　　 　　　　）"]
[null,"施術の種類",null,null,null,null,null,"１．マッサージ　　　　　　　２．変形徒手矯正術"]
["症　　　　状","施術部位",null,null,null,null,null,"１．躯幹　 ２．右上肢 　３．左上肢　 ４．右下肢 　５．左下肢"]
[null,"初療年月日",null,null,null,null,null,"　　　     年　　　月　　　日"]
[null,"施術月",null,null,null,null,null,"上記初療日以降で直近2年間に、月16回以上の施術が5か月以上実施されている施術月"]
[null,null,null,null,null,null,null,"令和　年　月",null,null,null,"令和　年　月",null,null,null,"令和　年　月",null,null,null,"令和　年　月",null,null,null,"令和　年　月"]
[null,"施術回数",null,null,null,null,null,"月　　　　　回　　（当該月の施術回数を記載）"]
[null,"患者の状態の評価",null,null,null,null,null,null,null,null,null,null,null,null,"評価日",null,null,"令和　　　年　　　月　　　日"]
[null,"基本動作","寝返り",null,null,null,null,"１．自立　　　　２．一部介助　　　　３．全介助"]
[null,null,"起き上がり",null,null,null,null,"１．自立　　　　２．一部介助　　　　３．全介助"]
[null,null,"座位",null,null,null,null,"１．自立　　　　２．一部介助　　　　３．全介助"]
[null,null,"立ち上がり",null,null,null,null,"１．自立　　　　２．一部介助　　　　３．全介助"]
[null,null,"立位",null,null,null,null,"１．自立　　　　２．一部介助　　　　３．全介助"]
[null,"前月の評価の有無",null,null,null,null,null,"１．有り　　　　２．無し"]
[null,"前月の状態からの改善や変化（前月の評価の有無が「有り」の場合に記入）"]
[null,null,"１．悪化　　２．維持　　３．改善小　　４．改善中　　５．改善大"]
[null,"（症状、経過及び初療の日から１年以上経過して、月１６回以上の施術が必要な理由）"]
[]
[]
[]
[]
[null,"　　上記のとおりであります。"]
[]
[null,"　　　　　　令和　　　年　　　月　　　日"]
[]
[null,"　　　　　　あん摩マッサージ指圧師氏名　　　　　　　　　　　　　　　　　　  "]
[]
[null,"備考　　この用紙は、Ａ列４番とすること。"]

{"sheet":"頻回施術理由（表）","index":5,"n_rows":22,"n_cols":27,"rows_kept":22,"cut":false,"hidden":false,"merged":[[1,1,2,20],[1,21,2,26],[3,0,6,0],[3,1,4,6],[3,7,3,9],[3,10,3,26],[4,7,4,9],[4,10,4,26],[5,1,5,6],[5,7,5,26],[11,1,11,26],[6,1,6,6],[6,7,6,26],[7,1,7,6],[7,7,7,26],[8,1,8,6],[8,7,8,26],[9,0,10,0],[9,1,9,6],[9,7,9,26],[10,1,10,6],[10,7,10,26],[21,1,21,26],[12,1,12,26],[13,1,14,26],[15,1,15,26],[16,1,17,26],[18,1,18,26],[19,1,20,26]]}
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"別添１（様式第11号の２）"]
[null,"頻回な施術を必要とした詳細な理由及び今後の施術計画書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（マッサージ用）"]
[]
["患　　　者","患者",null,null,null,null,null,"氏名"]
[null,null,null,null,null,null,null,"生年月日",null,null,"明 ・ 大 ・ 昭 ・ 平 ・ 令　　　　年　　　月　　　日"]
[null,"傷病名"]
[null,"症状",null,null,null,null,null,"１．筋麻痺　 ２．関節拘縮 　３．その他（                    )"]
[null,"施術の種類",null,null,null,null,null,"１．マッサージ　 　　　　　 ２．変形徒手矯正術"]
[null,"施術部位",null,null,null,null,null,"１．躯幹　２．右上肢　　３．左上肢　　４．右下肢　　５．左下肢"]
[null,"初療年月日",null,null,null,null,null,"平 ・ 令　　　年　　　月　　　日"]
[null,"施術回数",null,null,null,null,null,"　　　　　回　　（当該月の施術回数を記載）"]
[null,"１．頻回な施術を必要とした詳細な理由について"]
[null,"（患者の症状、経過を時系列で記載すること）"]
[]
[]
[null,"（上記に対する施術師の所見を記載すること）"]
[]
[]
[null,"（２年以上経過してもなお月16回以上の施術が必要な詳細な理由を記載すること）"]
[null,"【裏面へ続く】"]
[]
[null,"※　（患者の症状、経過を時系列で記載すること）及び（上記に対する施術師の所見を記載すること）については、施術録の\n  （写）添付でも差し支えない。"]

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[]
[null,"２．今後の施術計画について"]
[null,"（今後の施術内容及び施術の頻度（月○回など具体的に記載すること））"]
[]
[null,"　（頻回月から現在までの症状経過（筋麻痺・関節拘縮等の症状について））"]
[]
[null,"　　（現在の状況）"]
[null,"　　　□　関節可動域制限\n　　　□　拘縮・変形\n　　　□　筋力低下\n　　　□　運動機能障害\n　　　　（□　麻痺　□　不随意運動　□　運動失調　□　パーキンソニズム）\n　　　□　筋緊張異常"]
[null,"　　（今後の施術計画（６ヶ月から１年先の目標））"]
[]
[null,"３．今後の施術計画に関する同意及び確認"]
[null,"　　（本人又は家族、親族の署名）"]
[]
[null,"　　上記のとおりであります。"]
[]
[null,"　　　　　　令和　　　年　　　月　　　日"]
[]
[null,"　　　　　　あん摩マッサージ指圧師氏名　　　　　　　　　　　　　　　　　　"]
[]
[null,"備考　　記載欄が不足する場合には、別葉にまとめて提出することは差し支えない。"]