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[null,"１　基本機能・起居動作に関連する項目についての特記事項"]
[null,"　1-1麻痺等の有無，1-2拘縮の有無、1-3寝返り、1-4起き上がり、1-5座位保持、1-6両足での立位、1-7歩行、1-8立ち上がり、1-9片足での立位、1-10洗身、1-11つめ切り、1-12視力、1-13聴力"]
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[null,"(","1‐2",")"]
[null,"(","1-3",")"]
[null,"(","1-4",")"]
[null,"(","1-5",")"]
[null,"(","1-6",")"]
[null,"(","1-7",")"]
[null,"(","1-8",")"]
[null,"(","1-9",")"]
[null,"(","1-10",")"]
[null,"(","1-11",")"]
[null,"(","1-12",")"]
[null,"(","1-13",")"]
[null,"２　生活機能に関連する項目についての特記事項"]
[null,"2-1移乗、2-2移動、2-3えん下、2-4食事摂取、2-5排尿、2-6排便、2-7口腔清潔、2-8洗顔、2-9整髪、2-10上衣の着脱、2-11ズボン等の着脱、2-12外出頻度"]
[null,"(","2‐1",")"]
[null,"(","2‐2",")"]
[null,"(","2‐3",")"]
[null,"(","2‐4",")"]
[null,"(","2‐5",")"]
[null,"(","2‐6",")"]
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[null,"(","2‐7",")"]
[null,"(","2‐8",")"]
[null,"(","2‐9",")"]
[null,"(","2‐10",")"]
[null,"(","2‐11",")"]
[null,"(","2‐12",")"]
[]
[null,"３　認知機能に関連する項目についての特記事項"]
[null,null,"3-1意思の伝達、3-2毎日の日課を理解、3-3生年月日をいう、3-4短期記憶、3-5自分の名前をいう、3-6今の季節を理解、3-7場所の理解、3-8徘徊、3-9外出して戻れない"]
[null,"(","3‐1",")"]
[null,"(","3‐2",")"]
[null,"(","3‐3",")"]
[null,"(","3‐4",")"]
[null,"(","3‐5",")"]
[null,"(","3‐6",")"]
[null,"(","3‐7",")"]
[null,"(","3‐8",")"]
[null,"(","3‐9",")"]
[null,"４　精神 ・行動障害に関連する項目についての特記事項"]
[null,null,"4-1被害的、4-2作話、4-3感情が不安定、4-4昼夜逆転、4-5同じ話をする、4-6大声を出す、4-7介護に抵抗、4-8落ち着きなし、4-9一人で出たがる、4-10収集癖、4-11物や衣服を壊す、4-12ひどい物忘れ、4-13独り言・独り笑い、4-14自分勝手に行動する、4-15話がまとまらない"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"５　社会生活への適応に関連する項目についての特記事項"]
[null,"　5-1清潔，5-2衣服着脱，5-3薬の内服，5-4金銭の管理，5-5電話の利用，5-6日常の意思決定","5-1薬の内服、5-2金銭の管理、5-3日常の意思決定、5-4集団への不適応、5-5買い物、5-6簡単な調理"]
[null,"(","5‐1",")"]
[null,"(","5‐2",")"]
[null,"(","5‐3",")"]
[null,"(","5‐4",")"]
[null,"(","5‐5",")"]
[null,"(","5‐6",")"]
[null,"６　特別な医療についての特記事項",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"過去14日間に受けた特別な医療について"]
[null,"　5-1清潔，5-2衣服着脱，5-3薬の内服，5-4金銭の管理，5-5電話の利用，5-6日常の意思決定","6特別な医療"]
[null,"(",null,"）"]
[null,"7　日常生活自立度に関連する項目についての特記事項"]
[null,"7-1障害高齢者の日常生活自立度（ねたきり度）"]
[null,"(","障害",")"]
[null,"7-2認知症高齢者の日常自立度"]
[null,"(","認知症",")"]
[null,null,null,null,null,null,null,null,"※必ず枠内に記入して下さい。本用紙に納まらない場合は、別紙を追加してください。"]
[null,"認定調査票（特記事項　別紙）"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[null,"(",null,")"]
[]
[null,"概況",null,null,"調査対象者の家族状況、調査対象者の居住環境（外出が困難になるなど日常生活に支障となるような環境の有無）、日常的に使用する機器・器械の有無等について特記すべき事項を記入してください。"]