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["サーベイランスNo",null,null,"自然歴\n調査\n開始",null,null,null,"死亡の場合",null,null,null,"初診日",null,null,null,"年",null,"月",null,null,"日","剖検施設",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1999,1917,2,21,"B","2. 青森県","2. 女","2. 申込　未","2. 成長ホルモン製剤"]
[null,null,null,null,null,null,null,"死因",null,null,null,"死亡日",null,null,null,"年",null,"月",null,null,"日","剖検医",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2000,1918,3,22,"C","3. 岩手県",null,null,"3. その他"]
["遺伝子検査",null,null,"申込",null,"年",null,"月",null,"日","申込番号",null,null,null,"同意取得状況",null,null,null,null,null,null,null,"同意者",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2001,1919,4,23,"D","4. 宮城県","1. 通院"]
["髄液検査",null,null,"申込",null,"年",null,"月",null,"日","申込番号",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,null,null,null,null,null,null,null,null,null,null,2002,1920,5,24,"E","5. 秋田県","2. 入院","1. 有","1. 家族性CJD"]
["イニシャル\n（姓・名）",null,"・",null,"性別",null,null,"生年月日",null,null,null,"年",null,null,"月",null,null,"日","満",null,"歳","カルテ番号",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,2003,1921,6,25,"F","6. 山形県","3. 在宅","2. 無","2. GSS (Gerstman-Sträussler-Scheinker病)"]
["住所等","出身地\n（都道府県：選択）\n（市町村：直接入力）",null,null,null,null,null,null,null,"主な生活場所\n（都道府県：選択）\n（市町村：直接入力）",null,null,null,null,null,null,null,"現在の住所\n（都道府県：選択）\n（市町村：直接入力）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2004,1922,7,26,"G","7. 福島県","4. 死亡","3. 不明","3. FFI (致死性家族性不眠症)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2005,1923,8,27,"H","8. 茨城県",null,null,null,"AD"]
["\n家族歴","続柄①",null,null,null,null,"その他",null,"※",null,"生年月日",null,null,"年",null,"月",null,"日","イニシャル",null,null,"・",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2006,1924,9,28,"I","9. 栃木県","1. 明治","1. 有","1. 拡散強調","DLB"]
[null,"続柄②",null,null,null,null,"その他",null,"※",null,"生年月日",null,null,"年",null,"月",null,"日","イニシャル",null,null,"・",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2007,1925,10,29,"J","10. 群馬県","2. 大正","2. 無だが異常","2. FLAIR","脳血管性"]
[null,"続柄③",null,null,null,null,"その他",null,"※",null,"生年月日",null,null,"年",null,"月",null,"日","イニシャル",null,null,"・",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2008,1926,11,30,"K","11. 埼玉県","3. 昭和","3. 正常","3. T2強調","その他"]
[null,"続柄\n④ ",null,null,null,null,"その他",null,"※",null,"生年月日",null,null,"年",null,"月",null,"日","イニシャル",null,null,"・",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2009,1927,12,31,"L","12. 千葉県","4. 平成"]
["職業歴","※",null,null,null,null,null,null,"食品嗜好など",null,null,null,null,null,null,null,"備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2010,1928,13,32,"M","13. 東京都",null,"1. 確実に有（下記）","1. 大脳皮質","1. 大脳皮質　有"]
["接触歴","他のCJD患者（組織等）との接触",null,null,null,null,null,"「有」の場合具体的に",null,null,null,null,null,null,null,null,"時期",null,null,"年",null,"月頃","期間　約",null,null,"ヶ月",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2011,1929,14,33,"N","14. 神奈川県","1. 治癒","2. 可能性が高い（下記）","2. 基底核","2. 大脳皮質　無"]
[null,"動物との職業的接触歴",null,null,null,null,null,"「有」の場合",null,null,null,null,null,"3．その他の場合",null,null,null,null,null,"動物",null,null,"期間　約",null,null,"ヶ月",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2012,1930,15,34,"O","15. 新潟県","2. 継続","3. 不明（可能性を否定はできない）","3.  視床","3.  基底核　有"]
[null,"海外\n渡航歴　",null,"イギリス",null,null,null,"時期",null,"年頃","期間　約",null,null,"ヶ月","特筆事項",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2013,1931,16,35,"P","16. 富山県","3. 死亡","4. 無","4. その他","4. 基底核　無"]
[null,null,null,"EU諸国",null,null,null,"時期",null,"年頃","期間　約",null,null,"ヶ月","国名",null,null,null,"特筆事項",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2014,1932,17,36,"Q","17. 石川県",null,null,null,5]
["既往歴","手術歴",null,null,null,null,null,null,null,null,null,null,null,null,null,"（疾患名）",null,null,null,null,"（実施施設）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2015,1933,18,37,"R","18. 福井県","1. 本人","1. 陽性","1. V180I",6]
[null,"1）","脳",null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2016,1934,19,38,"S","19. 山梨県","2. 代諾者","2. 陰性","2. P102L",7]
[null,"2）","脊髄",null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2017,1935,20,39,"T","20. 長野県",null,"3. 未実施","3. E200K"]
[null,"3）","他の神経系",null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2018,1936,21,40,"U","21. 岐阜県","1. 父",null,"4. M232R"]
[null,"4）","外傷",null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2019,1937,22,41,"V","22. 静岡県","2. 母","1. 確実例","5. P105L"]
[null,"5）","他の手術",null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2020,1938,23,42,"W","23. 愛知県","3. 兄弟","2. ほぼ確実例","6. Insertion"]
[null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2021,1939,24,43,"X","24. 三重県","4. 姉妹","3. 疑い例","7. D178N-129V"]
[null,"硬膜移植",null,null,null,null,null,null,null,null,null,null,"実施時期",null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2022,1940,25,44,"Y","25. 滋賀県","5. 祖父（父方）","4. 該当せず","8. R208H"]
[null,"　使用硬膜製品名",null,null,null,null,null,null,null,"Lot No.",null,null,null,null,null,null,"サイズ　　　　　　　cm×　　　　　　　cm",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2023,1941,26,45,"Z","26. 京都府","6. 祖母（父方）",null,"9. V180I+M232R"]
[null,"　手術名",null,null,null,null,null,null,null,"手術実施施設名",null,null,null,null,null,null,null,null,null,null,"主治医名",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,2024,1942,27,46,null,"27. 大阪府","7. 祖父（母方）","1. 鑑別できる","10. V210I"]
[null,"その他の臓器移植・製剤による治療歴",null,null,null,null,null,null,null,null,null,null,"「１．有」の場合",null,null,null,null,null,"具体的に",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2025,1943,28,47,null,"28. 兵庫県","8. 祖母（母方）","2. 鑑別できない","11. A117V-129V"]
[null,null,"実施時期",null,null,null,"年",null,"月",null,"日",",",null,null,null,"実施施設名",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,null,null,null,2026,1944,29,48,null,"29. 奈良県","9. その他",null,"12. その他"]
[null,"　歯科（インプラント術）",null,null,null,null,null,null,null,null,"年",null,"月",null,"日","実施施設名",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,null,null,null,2027,1945,30,49,null,"30. 和歌山県",null,"1. 急速進行型","13 なし"]
[null,"　輸血歴",null,null,null,null,null,null,null,null,"年",null,"月",null,"日","実施施設名",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,null,null,null,2028,1946,31,50,null,"31. 鳥取県",null,"2. 緩徐進行型","1. Met/Met"]
[null,"　献血歴",null,null,null,null,null,null,null,null,"年",null,"月",null,"日","実施施設名",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,null,null,null,2029,1947,"1～10",51,null,"32. 島根県",null,"3. 不明","2. Met/Val"]
[null,"　鍼治療歴",null,null,null,null,null,null,null,null,"年",null,"月",null,"日","実施施設名",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,null,null,null,2030,1948,"11～20",52,null,"33. 岡山県","1. 牛",null,"3. Val/Val"]
[null,"　内視鏡検査歴",null,null,null,null,null,null,null,null,"年",null,"月",null,"日","実施施設名",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,null,null,null,2031,1949,"21～31",53,null,"34. 広島県","2. 羊","1. 診断不明 (プリオン病の診断基準には合致しないが，診断不明でプリオン病の可能性は残る例。要追跡調査)"]
[null,"　既往歴",null,null,null,null,null,"病名",null,null,null,null,null,null,"発症",null,"年",null,"月",null,"日","転帰",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2032,1950,1,54,null,"35. 山口県","3. 山羊","2. ほぼ否定 (他の疾患の可能性が高いが確定診断に至ってない例)","1. Glu/Glu"]
[null,null,null,null,null,null,null,"病名",null,null,null,null,null,null,"発症",null,"年",null,"月",null,"日","転帰",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2033,1951,2,55,null,"36. 徳島県","4. 豚","3. 確実に否定 (他の疾患の確定診断が可能な例)","2. Glu/Lys"]
["検査","1）","脳波",null,null,null,null,"時期",null,"年",null,"月",null,"日","PSD",null,null,null,null,"2.無の場合（基礎律動の徐波化）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2034,1952,3,56,null,"37. 香川県","5. 馬",null,"3. Lys/Lys"]
[null,"2）","画像検査（CT）",null,null,null,null,"時期",null,"年",null,"月",null,"日","検査施設",null,null,null,null,null,null,"MRI\n撮\n影\n法","DWI",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2035,1953,4,57,null,"38. 愛媛県","6. 鹿"]
[null,null,"画像検査（MRI）",null,null,null,null,"時期",null,"年",null,"月",null,"日","検査施設",null,null,null,null,null,null,null,"FLAIR",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2036,1954,5,58,null,"39. 高知県","7. 不明・その他","1. プリオン病","1. MM1"]
[null,"　　　　 DWI上高信号","DWI上高信号",null,null,"大脳皮質",null,null,"基底核",null,null,"視床",null,null,"その他",null,null,null,null,null,null,null,"T2強調",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2037,1955,6,59,null,"40. 福岡県","1. と畜","2. 認知症","2. MV1"]
[null,"3）","脳脊髄液検査",null,null,null,null,"実施の場合",null,null,"年",null,"月",null,"日","施設",null,null,null,"2.その他",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2038,1956,7,60,null,"41. 佐賀県","2. 牧畜等","3. その他","3. VV1"]
[null,null,"14-3-3",null,null,null,null,null,null,null,"ug/ml","総タウ",null,null,null,null,null,null,"pg/ml","RT-QUIC",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2039,1957,8,61,null,"42. 長崎県","3. その他",null,"4. MM2"]
[null,null,"蛋白量　※",null,null,null,null,null,null,null,"mg/dl","NSE　※",null,null,null,null,null,"ng/ml",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2040,1958,9,62,null,"43. 熊本県",null,null,"5. MV2"]
[null,null,"細胞数　※",null,null,null,null,null,null,"/μl",null,"※3箇所：蛋白量と細胞数とNSEは各ご施設で測定した値を入力ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2041,1959,10,63,null,"44. 大分県","1. プリオン病",null,"6. VV2"]
[null,"4）","プリオン蛋白（PrP）遺伝子検査",null,null,null,null,null,null,"施設",null,null,"2.その他\nの場合",null,null,null,null,"★検査材料：抹消全血（4℃）・DNA（4℃）　搬送時ドライアイス不要\n　＊臨床調査個人票の控えがありましたら添付ください。\n　＊退院時には、退院時サマリーをお送りください。\n　＊剖検・生検その他により診断が確定した場合にはご連絡ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2042,1960,11,64,null,"45. 宮崎県","2. 認知症"]
[null,null,"コドン129の多型",null,null,null,null,"コドン219の多型",null,null,null,null,"変異の有無",null,null,"有の場合",null,null,null,null,null,"「その他」\n詳細",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2043,1961,12,65,null,"46. 鹿児島県","3. その他"]
[null,null,"検査時期",null,null,null,"年",null,"月",null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2044,1962,13,66,null,"47. 沖縄県",null,null,"1.無"]
[null,"5)","検体検査",null,null,null,null,"異常所見",null,null,null,"具体的に",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2045,1963,14,67,null,"48. 海外","1. 全身剖検実施",null,"2.プリオン病"]
[null,null,"生理機能検査",null,null,null,null,"異常所見",null,null,null,"具体的に",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2046,1964,15,68,null,"49. 不明","2. 脳剖検のみ実施",null,"3.認知症"]
["WHO\n基準\nによる\n症状","経過","進行型",null,null,null,null,"「不明」の理由",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2047,1965,16,69,null,null,"3. 実施せず",null,"4.脊髄小脳変性症"]
[null,"症状","初発症状",null,null,null,null,null,null,null,null,null,null,null,null,null,"症状の出現した時期",null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2048,1966,17,70,null,null,"4. その他",null,"5.痙性対麻痺"]
[null,"1）","ミオクローヌス",null,null,null,null,null,null,null,"備\n\n\n\n考",null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2049,1967,18,71,null,null,null,null,"6.その他※欄に記入"]
[null,"2）","進行性認知症",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2050,1968,19,72,null,null,"1. サーベイランス登録のみ同意"]
[null,"3）","小脳症状",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1969,20,73,null,null,"2. 自然歴調査についても同意"]
[null,"4）","錐体路徴候",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1970,21,74]
[null,"5）","錐体外路徴候",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1971,22,75]
[null,"6）","意識障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1972,23,76,null,null,"1. Ⅰ型"]
[null,"7）","感覚障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1973,24,77,null,null,"2. Ⅱ型"]
[null,"8）","視覚障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1974,25,78,null,null,"3. その他"]
[null,"9）","精神症状",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1975,26,79]
[null,"10）","無動性無言",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1976,27,80,null,null,"1. 鑑別できる"]
["その他\nの症状","1）","起立・歩行障害",null,null,null,null,null,null,null,"備\n\n考",null,null,null,null,null,"症状の出現した時期",null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1977,28,81,null,null,"2. 鑑別できない"]
[null,"2）","構音障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1978,29,82]
[null,"3）","嚥下障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1979,30,83,null,null,"1. 生検"]
[null,"4）","膀胱・直腸障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1980,31,84,null,null,"2. 剖検"]
[null,"5）","てんかん発作",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1981,null,85]
["ADL","1）","発話能力の障害",null,null,null,null,null,null,null,"備\n\n考",null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1982,null,86,null,null,"1. CJD典型"]
[null,"2）","歩行障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1983,null,87,null,null,"2. その他 (視床型等)"]
[null,"3）","食事不能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1984,null,88]
[null,"4）","人工呼吸器使用",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1985,null,89,null,null,"1. 施設に設備がない"]
[null,"5）","気管切開",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1986,null,90,null,null,"2. 患者が器具を装着している"]
["その他\nの症状","症状１",null,null,null,null,null,null,null,null,null,null,null,null,null,"症状の出現",null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1987,null,91,null,null,"3. 患者の病状"]
[null,"症状2",null,null,null,null,null,null,null,null,null,null,null,null,null,"症状の出現",null,null,null,"年",null,"月",null,null,"日頃",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1988,null,92,null,null,"4．その他"]
["鑑別\n診断","1）","アルツハイマー型認知症",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1989,null,93]
[null,"2）","FTD (ピック病など)",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1990,null,94,null,null,"1. 東北大学",null,"1.長崎大学"]
[null,"3）","脳血管性認知症",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1991,null,95,null,null,"2. その他",null,"2.その他"]
[null,"4）","脊髄小脳変性症（痙性対麻痺を含む）",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1992,null,96]
[null,"5）","パーキンソン症候群",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1993,null,97,null,null,"1.有","1.増多","1.実施","1.検査済"]
[null,"6）","認知症を伴う運動ニューロン疾患",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1994,null,98,null,null,"2.無","2.正常","2.未実施","2.未検査"]
[null,"7）","単純ヘルペス等のウイルス性脳炎",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1995,null,99,null,null,null,"3.不明","3.実施予定"]
[null,"8）","脳原発性リンパ腫",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1996,null,100,null,null,"1.誤記修正"]
[null,"9）","代謝性脳症・低酸素脳症",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1997,null,null,null,null,"2.新たな情報入手"]
[null,"10）","末梢神経障害",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1998,null,null,null,null,"3.再考"]
[null,"11）","その他の病因による認知症性疾患",null,null,null,null,null,null,null,null,null,null,null,"理由・備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1999,null,null,null,null,"4.その他"]
["診断","1）孤発性クロイツフェルト・ヤコブ病（sCJD）",null,null,null,null,null,null,null,null,null,null,null,null,null,"型","※コドン129の多型とWestern blotの型による",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,2000]
[null,null,null,null,null,null,"　1. 確実例\n　　特徴的な病理所見を有する又はウェスタンブロット法や免疫染色法で脳に異常PrPを検出。\n　2. ほぼ確実例\n　　病理所見がない症例で，進行性認知症を示し，脳波でPSDを認める．更に，ミオクローヌス，錐体路/錐体外路障害，\n　　小脳症状/視覚異常，無言・無動状態のうち2項目以上示す。あるいは、「3.疑い例」に入る例で、髄液14-3-3蛋白陽性で\n　　全臨床経過が2年未満\n　3. 疑い例\n　　ほぼ確実例と同じ臨床症状を呈するが，PSDを欠く",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2001]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2002]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2003]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2004]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2005]
[null,"2）獲得性クロイツフェルト・ヤコブ病",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2006]
[null,"　（1）医原性クロイツフェルト・ヤコブ病 (sCJDと同様の診断基準による）",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,2007]
[null,"　（2）変異型クロイツフェルト・ヤコブ病（vCJD）(WHO 2001 診断基準）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2008]
[null,"3）遺伝性プリオン病",null,null,null,null,null,null,null,null,null,null,null,"  1. 確実例　　：　特徴的な病理所見を有する又はウェスタンブロット法や免疫染色法 で脳に異常PrPを検出し，PrP遺伝子変異を有するもの\n　2. ほぼ確実例　　：　 病理所見はないが，PrP遺伝子変異を認め，　臨床所見が矛盾 しないもの\n　3. 疑い例　　：　病理所見がなく，PrP遺伝子変異も証明されていないが，遺伝性プリオン病 を示唆する臨床所見と 家族歴があるもの",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2009]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2010]
[null,"　　種類と変異",null,null,null,"   「その他」の場合のPrP遺伝子変異",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2011]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2012]
[null,"4）その他",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2013]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2014]
[null,null,null,null,null,"「2」の場合、疑われる診断名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2015]
[null,null,null,null,null,"「3」の場合、診断名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2016]
[null,null,"【診断の根拠となる臨床経過、神経所見、検査所見など】\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2017]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2018]
["脳病理\n（資料添付",null,null,"1. 3.の場合",null,null,null,null,null,"標本の所在",null,null,null,null,null,null,null,null,null,"標本番号",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,null,null,2019]
[null,"病理海綿状変化",null,null,null,null,",クールー斑",null,null,null,null,"病型",null,null,null,null,null,"2.の場合具体的に",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2020]
[null,"異常PrP検出：PrP免疫染色",null,null,null,null,null,null,"1.の場合具体的に",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2021]
[null,"PrP Westernブロット",null,null,null,null,null,null,"1.の場合",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2022]
["転出\n（予定）","転院予定",null,null,null,"転院予定時期",null,null,null,null,"年",null,"月",null,null,"日頃","紹介元医\n療機関名",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,null,null,null,2023]
[null,"転院（予定）先",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2024]
["都道府県\nCJD担当\n専門医\n（該当する場合）","【コメント】（全角165文字まで）",null,null,null,null,null,null,null,null,null,null,null,null,"所属・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,null,null,null,null,null,2025]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所属",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2026]
[null,null,null,null,null,null,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,null,null,null,null,null,2027]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2028]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2029]
["サーベイラ\nンス委員","【コメント】（全角165文字まで）",null,null,null,null,null,null,null,null,null,null,null,null,"所属・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,null,null,null,null,null,2030]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所属",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2031]
[null,null,null,null,null,null,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,null,null,null,null,null,2032]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2033]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2034]
["主治医\n所属\n施設","主治医氏名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2035]
[null,"所属施設名・科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2036]
[null,"住所",null,null,"〒",null,null,"－",null,null,"都道府県",null,null,null,null,"ブロック",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2037]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2038]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2039]
[null,"電話番号",null,null,null,null,null,null,null,null,null,null,"ＦＡＸ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,null,null,null,null,null,null,null,null,null,2040]
[null,"e-mail",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2041]
[null,"＊特定疾患個人調査票の控えがありましたら添付下さい。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2042]
[null,"＊お手数ですが退院時には退院時サマリーをお送り下さい。また、剖検、生検その他により診断が確定した場合はご連絡下さい。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2043]
["Modified Rankin Scale",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2044]
[null,"Grade 0:全く障害が存在しない",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2045]
[null,"Grade 1:症状があっても、明らかな障害は存在しない。通常の動作を補助なしで行うことができる。",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,2046]
[null,"Grade 2:軽度の障害。いくつかの日常動作を行うことができない。しかし多くの介助はなくても自分の身の回り\nのことができる。",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,2047]
[null,"Grade 3:中等度の障害。ある程度の介助を必要とするが、助けなしで歩くことができる。",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,2048]
[null,"Grade 4:中程度～重度の障害。介助なしでは歩いたり身体の位置を好きなように動かすことができない。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2049]
[null,"Grade 5:重度の困難。ベッド臥床、失禁、継続的な看護と監視が必要とされる。",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,2050]
[]
[null,"MRI 拡散強調画像で高信号領域を下記の図に斜線にてお示ししてください。"]
["■作画方法"]
["1.「挿入」"]
["↓"]
["2.「図」"]
["↓"]
["3.「図形」"]
["↓"]
["4.「線」"]
["↓"]
["5.「フリーフォーム」又は「フリーハンド」"]
["↓"]
["★編集する場合"]
["↓"]
["6.「図形の書式設定」"]
["↓"]
["7.「塗りつぶし（単色など）+透明度」の設定"]
[null,"*サンプル"]
[null,"↓"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"-","-","A","1. 急速進行型"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1999,1,"B","2. 緩徐進行型"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2000,2,"C","3．不明"]
["プリオン病自然歴　調査票　【医師診察】",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2001,3,"D"]
["【MRCスコア】",null,null,"黄色の枠内をご記載ください。ボタンを選択することで自動でスコア入力されます。",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,2002,4,"E","1. 有",1]
["調査日",null,"西暦",null,null,null,"年",null,null,"月",null,null,"日","サーベイランス\nＮｏ．",null,null,null,null,null,null,"調査",null,"―",null,"回目",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2003,5,"F","2. 無"]
["イニシャル*",null,null,null,"・",null,null,"*ヘボン式ローマ字",null,null,"回答者",null,null,null,null,null,null,"回答者がその他の場合は記載",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2004,6,"G","3. 不明",1]
["（姓・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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2005,7,"H"]
["日常生活動作",null,"　　1) 排便機能",null,null,null,null,null,null,null,"直近の7日間で便失禁が一回以上あった",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE161-1","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2006,8,"I","1．実施",1]
[null,null,null,null,null,null,null,null,null,null,"直近の7日間には便失禁なし",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2007,9,"J","2．前回調査以降実施せず"]
[null,null,"　　2) 排尿機能",null,null,null,null,null,null,null,"常に失禁しているか、カテーテル処置をしている",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE163-1","v":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,null,2008,10,"K","3．不明"]
[null,null,null,null,null,null,null,null,null,null,"排泄を制御できているか、まれに失禁する",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,2009,11,"L",null,1]
[null,null,"　　3) トイレの使用",null,null,null,null,null,null,null,"全介助",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE165-1","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2010,12,"M","1. 有"]
[null,null,null,null,null,null,null,null,null,null,"部分介助",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2011,13,"N","2. 無だが異常",1]
[null,null,null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2012,14,"O","3. 正常"]
[null,null,"　　4) 入浴",null,null,null,null,null,null,null,"全介助あるいは部分介助",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE168-1","v":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,null,2013,15,"P"]
[null,null,null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2014,16,"Q","1. 経鼻経管栄養",1]
[null,null,"　　5) 食事",null,null,null,null,null,null,null,"不能または経鼻/胃瘻栄養法/RIG fed※　(経口では何も摂取できない)",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE170-1","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2015,17,"R","2. 胃瘻"]
[null,null,null,null,null,null,null,null,null,null,"介助 （嚥下の危険の有無は問わない）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2016,18,"S","3. 末梢持続栄養"]
[null,null,null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2017,19,"T","4. 中心静脈栄養",1]
[null,null,"　　6) 移動",null,null,null,null,null,null,null,"寝たきり、座ることもできない",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE173-1","v":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,null,2018,20,"U","5. その他"]
[null,null,null,null,null,null,null,null,null,null,"座ることはできるが、移動は介助を要する （人による介助、杖による介助を問わず",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2019,21,"V"]
[null,null,null,null,null,null,null,null,null,null,"自立",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2020,22,"W","1. 主治医",1]
[null,null,"　　7) 階段の昇降",null,null,null,null,null,null,null,"不能",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE176-1","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2021,23,"X","2.患者本人"]
[null,null,null,null,null,null,null,null,null,null,"要介助",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2022,24,"Y","3.代諾者"]
[null,null,null,null,null,null,null,null,null,null,"自力で階段の昇降が可能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2023,25,"Z","4.その他"]
[null,null,"　　8) 言語反応性",null,null,null,null,null,null,null,"無言",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE179-1","v":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,null,2024,26]
[null,null,null,null,null,null,null,null,null,null,"発声はあるが理解不能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2025,27,null,"●",1]
[null,null,null,null,null,null,null,null,null,null,"単語レベルの発語",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2026,28,null,"－"]
[null,null,null,null,null,null,null,null,null,null,"文章によって受け答えするが、換語の困難や不適切な単語の使用などがあり、\nしばしば見当識障害や混乱を認める",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,2027,29]
[null,null,null,null,null,null,null,null,null,null,"通常の会話が可能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2028,30,null,0]
[null,null,"　　9) 記憶及び環境への順応",null,null,null,null,null,null,null,"周囲の状況に関心がないか、過去の記憶が残っていない",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE184-1","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2029,31,null,1,1]
[null,null,null,null,null,null,null,null,null,null,"親しい人物などよく知っていることは認識している形跡がある、または\n周囲の状況に気付いてはいるが、新しい事柄を認識している形跡はない",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2030,"1～10（上旬）",null,2]
[null,null,null,null,null,null,null,null,null,null,"新しい情報を保持できているが、常に記憶に障害がある",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2031,"11～20（中旬）",null,3,1]
[null,null,null,null,null,null,null,null,null,null,"記憶は正常か、ごく軽度の物忘れがある",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2032,"21～31（下旬）",null,4]
[null,null,"　　10) 判断と問題解決能力",null,null,null,null,null,null,null,"判断力や問題解決能力はない",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE188-1","v":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,null,2033]
[null,null,null,null,null,null,null,null,null,null,"判断力や問題解決能力が少しでも残っている",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,2034]
[null,null,"　　11) 道具の使用",null,null,null,null,null,null,null,"道具や器具の使用が全くできない",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"BE190-1","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2035]
[null,null,null,null,null,null,null,null,null,null,"必要な場合には、介助があれば道具や器具を使用することができる",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2036]
["合　　計",null,null,null,null,null,null,null,null,null,"※RIG (radiological inserted gastrostomy)；X線透視下胃瘻造設術。非手術的胃瘻チューブ留置方法。\n本邦では、PEG (percutaneous endoscopic gastrostomy) 経皮内視鏡的胃瘻造設術を用いることも多い。　",null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"SUM(Y165:Z195)","v":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,null,2037]
["メモ",null,"　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2038]
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[]
["担当医師所属",null,"*３ページの【主治医所属施設】の欄に変更が無ければ記載不要\n",null,null,null,null,null,null,null,null,null,null,"担当医師氏名",null,null,null,"*３ページの【主治医所属施設】の欄に変更が無ければ記載不要\n\n"]
[]
["電話番号",null,"*３ページの【主治医所属施設】の欄に変更が無ければ記載不要",null,null,null,null,null,null,null,null,null,null,"e-mail",null,null,null,"*３ページの【主治医所属施設】の欄に変更が無ければ記載不要",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2014,null,"A","1. 主治医・看護職",null,"●"]
["変更・修正記録",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2015,1,"B","2. 代諾者",null,"－"]
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["\n※　ブロック担当医の先生へ　：　調査票を変更・修正された場合は、下記に変更・修正内容を記録してください",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2017,3,"D","4. 患者本人"]
["変更・修正箇所",null,null,"変更前",null,null,null,"変更後",null,null,null,"変更記載者",null,null,"変更日",null,null,"確認方法",null,null,"変更理由",null,"備考",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2018,4,"E","5. その他"]
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ン疾患","認知症を伴う運動ニューロン疾患_理由・備考","単純ヘルペス等のウイルス性脳炎","単純ヘルペス等のウイルス性脳炎_理由・備考","脳原発性リンパ腫","脳原発性リンパ腫_理由・備考","代謝性脳症・低酸素脳症","代謝性脳症・低酸素脳症_理由・備考","末梢神経障害","末梢神経障害_理由・備考","その他の病因による認知症性疾患","その他の病因による認知症性疾患_理由・備考","孤発性クロイツフェルト・ヤコブ病_sCJD","孤発性クロイツフェルト・ヤコブ病_sCJD_型","医原性クロイツフェルト・ヤコブ病","変異型クロイツフェルト・ヤコブ病","遺伝性プリオン病","遺伝性プリオン病_詳細","遺伝性プリオン病_種類","遺伝性プリオン病_その他詳細","その他診断結果","診断名","診断の根拠","脳病理検査","脳病理検査_種類","標本の所在","標本番号","病理海綿状変化","クールー斑","病型","病型_その他詳細","異常PrP検出","異常PrP検出_詳細","PrP_Westernブロット","PrP_Westernブロット_型","PrP_Westernブロット_型_詳細","転院予定","転院予定時期_年","転院予定時期_月","転院予定時期_日","転院予定時期_旬","転院先","紹介元医療機関名","都道府県CJD担当専門医_コメント","都道府県CJD担当専門医_所属","都道府県CJD担当専門医_氏名","サーベイランス委員_コメント","サーベイランス委員_所属","サーベイランス委員_氏名","主治医氏名","所属施設名・科","所属施設_郵便番号","主治医所属施設都道府県","所属施設_住所","所属施設_電話番号","所属施設_FAX番号","所属施設_email"]