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[null,null,null,null,null,null,"健康食品との関連が疑われる健康被害情報提供票",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ver:",null,2025100101]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"整理番号："]
["会社名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"都道府県名\n（保健所名）\n※事業者が情報提供者への聞き取りにあたって使用する場合は記載不要"]
["担当者名"]
["所在地"]
["電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"情報受付日"]
["情報提供者",null,null,null,null,null,null,"□","摂取者本人",null,null,null,null,null,null,"□","摂取者の家族等",null,null,null,null,null,null,null,null,"□","医療機関"]
[null,null,null,null,null,null,null,"□","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,"）"]
["○：１つのみ選択　□：複数選択可"]
["該当する健康食品にチェックしてください"]
["○",null,"特定保健用食品",null,null,null,null,null,null,"許可番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["○",null,"機能性表示食品",null,null,null,null,null,null,"届出番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["○",null,"栄養機能食品"]
["○",null,"その他のいわゆる「健康食品」"]
["食品衛生法第8条に基づく指定成分等含有食品に該当するか",null,null,null,null,null,null,"○","はい",null,null,null,null,null,"○","いいえ"]
[null,null,null,null,null,null,"　はいの場合："]
[null,null,null,null,null,null,null,"□","コレウス・フォルスコリー",null,null,null,null,null,null,"□","ドオウレン",null,null,null,"□","プエラリア・ミリフィカ",null,null,null,null,null,null,"□","ブラックコホシュ"]
["食品衛生法施行規則別表第17の第9のハに基づく情報の提供(義務対象)に該当するか",null,null,null,null,null,null,"○","はい",null,null,null,null,null,"○","いいえ"]
[null,null,null,null,null,null,"　はいの場合："]
[null,null,null,null,null,null,null,"□","重篤事例"]
[null,null,null,null,null,null,null,"□","概ね30日以内に同じ所見の症例が複数発生している"]
[null,null,null,null,null,null,null,"概ね30日以内に同じ所見の症例が複数発生している場合："]
[null,null,null,null,null,null,null,null,"○","この健康被害情報提供票が1例目である。(同日に複数の情報提供をする場合の1件目の提出)"]
[null,null,null,null,null,null,null,null,"○","同じ所見の症例の健康被害情報提供票を既に提出している。"]
[null,null,null,null,null,null,null,"1例目の症例を\n提出した際の整理番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","整理番号不明"]
[null,null,null,null,null,null,"健康被害を診断した医療機関名を知った日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","情報受付日に同じ"]
["指定成分等含有食品である場合",null,null,null,null,null,"指定成分等及び管理成分の１日摂取目安量"]
[null,null,null,null,null,null,null,"成分等の名称",null,null,null,null,null,null,null,null,null,null,null,"1日摂取目安量（μｇ/ｍｇ/ｇ）"]
[null,null,null,null,null,null,1]
[null,null,null,null,null,null,2]
[null,null,null,null,null,null,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
[null,null,null,null,null,null,4]
[null,null,null,null,null,null,5]
["以下のいずれかの\n健康食品である場合\n・特定保健用食品\n・機能性表示食品",null,null,null,null,null,"関与成分等の１日摂取目安量"]
[null,null,null,null,null,null,null,"関与成分等名",null,null,null,null,null,null,null,null,null,null,null,"1日摂取目安量（μｇ/ｍｇ/ｇ/個）"]
[null,null,null,null,null,null,1]
[null,null,null,null,null,null,2]
[null,null,null,null,null,null,3]
[null,null,null,null,null,null,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
[null,null,null,null,null,null,5]
[null,null,null,null,null,null,"そ\nの\n他"]
[]
[]
["１．該当する製品情報"]
["製品名"]
["製品形状",null,null,null,null,null,null,"○","錠剤",null,null,null,"○","カプセル",null,null,null,"○","液剤",null,null,null,"○","粉末・顆粒",null,null,null,null,null,"○","グミ"]
[null,null,null,null,null,null,null,"○","その他の加工食品（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"○","生鮮食品",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["原材料名\n(表示順に全て記入)\n\n※「７．添付ファイル」に製品画像を添付することで記載省略可"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
[]
[]
[]
[]
[]
[]
[]
[]
["製造者名",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,"○","不明"]
["製造者所在地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["製造者電話番号",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,"○","不明"]
["販売者名",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,"○","製造者に同じ",null,null,null,null,"○","不明"]
["販売者所在地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","製造者に同じ",null,null,null,null,"○","不明"]
["販売者電話番号",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,"○","製造者に同じ",null,null,null,null,"○","不明"]
["製造所名",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,"○","製造者に同じ",null,null,null,null,"○","不明"]
["製造所所在地",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","製造者に同じ",null,null,null,null,"○","不明"]
["製造所電話番号",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,"○","製造者に同じ",null,null,null,null,"○","不明"]
["ロット番号"]
[null,null,null,null,null,null,null,"○","不明",null,null,"（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,"）"]
["製品の1日当たり\n摂取目安量",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["購入日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"消費/賞味期限",null,null,null,null,null,null,"▼選択▼"]
[null,null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"○","不明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["当該製品の販売数量",null,null,null,null,null,null,"□","累計の販売数　　(",null,null,null,null,null,null,null,null,null,null,null,null,")","販売期間（",null,null,null,null,null,null,"） ～ （",null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"□","同ロットの販売数（",null,null,null,null,null,null,null,null,null,null,null,null,")","販売期間（",null,null,null,null,null,null,"） ～ （",null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"□","不明"]
["類似例の情報提供",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明"]
[null,null,null,null,null,null,"ある場合その詳細："]
[]
[]
[]
[]
[]
["２．摂取者および摂取状況に関する情報"]
["個人情報（氏名・連絡先）について行政への提供を",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","同意する",null,null,null,null,"○","同意しない"]
["　※同意が得られない場合は、氏名、連絡先は記入せず、「６．その他」の備考欄にその理由を可能な範囲で記入すること。"]
["氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"連絡先\n(住所・電話番号等)"]
["性別",null,null,null,null,null,null,"○","男",null,null,null,"○","女",null,null,null,"○","その他・不明"]
["年齢",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"▼選択▼",null,null,null,null,null,null,null,null,null,null,"○","不明"]
["当該製品の\n入手方法",null,null,null,null,null,null,"□","店頭販売",null,null,null,null,"□","（ネット）通販",null,null,null,null,"□","メーカー直販の\n（ネット）通販",null,null,null,null,"□","訪問販売",null,null,null,null,"□","個人輸入"]
[null,null,null,null,null,null,null,"□","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,"□","不明"]
["当該製品の有無\n（摂取した製品が残っているかどうか）",null,null,null,null,null,null,"○","あり（摂取者の手元）",null,null,null,null,null,null,null,"○","あり（事業者へ返品）",null,null,null,null,null,null,null,"○","なし",null,null,null,null,null,null,"○","不明"]
["摂取目的",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["症状・主訴",null,null,null,null,null,"  　　発熱","□","食欲不振",null,null,null,null,"□","吐気・悪心",null,null,null,null,null,"□","嘔吐",null,null,null,null,null,"□","下痢",null,null,null,null,"□","黄疸"]
[null,null,null,null,null,null,"  　　頭痛","□","腹痛",null,null,null,null,"□","頭痛",null,null,null,null,null,"□","その他の体の痛み(部位：",null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","倦怠感",null,null,null,null,"□","めまい・ふらつき",null,null,null,null,null,"□","動悸",null,null,null,null,null,"□","息切れ・呼吸困難"]
[null,null,null,null,null,null,null,"□","けいれん・失神",null,null,null,null,"□","かゆみ・発疹",null,null,null,null,null,"□","手足の浮腫",null,null,null,null,null,"□","発熱"]
[null,null,null,null,null,null,null,"□","月経不順",null,null,null,null,"□","不正性器出血",null,null,null,null,null,"□","頻尿",null,null,null,null,null,"□","尿の回数・量の減少"]
[null,null,null,null,null,null,null,"□","自覚症状なし"]
[]
[null,null,null,null,null,null,"その他（上記以外の症状、健診・受診時の臨床検査値の異常、症状経過等）"]
[null,null,null,null,null,null,null,"○","あり",null,null,null,null,null,"○","なし"]
[null,null,null,null,null,null,null,null,"具体的な内容："]
[]
[]
[]
[]
["同症状の方の有無",null,null,null,null,null,"周囲（家族、友人など)に同じ製品の摂取により同様の症状の方がいるか"]
[null,null,null,null,null,null,null,"○","いる",null,null,null,"○","いない",null,null,null,"○","同じ製品を摂取している人がいない",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["摂取開始日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 摂取中止日"]
[null,null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,"その他（",null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"○","不明",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["症状発現日\n（自覚症状なしの場合は検査日）",null,null,null,null,null,null,null,null,null,null,null,null,null,"または",null,null,null,null,"摂取後(約)",null,null,"▼選択▼"]
[null,null,null,null,null,null,null,"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,"○","不明"]
[" 症状発現後の摂取状況・症状\n",null,null,null,null,null,null,"□","中止",null,null,null,null,"→",null,"中止後に症状改善：",null,null,null,null,null,null,"○","あり",null,null,"○","なし",null,null,null,null,null,"○","不明"]
[null,null,null,null,null,null,null,"□","中止後再使用",null,null,null,null,"→",null,"再摂取で症状再発：",null,null,null,null,null,null,"○","あり",null,null,"○","なし",null,null,null,null,null,"○","不明"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"再摂取日",null,null,null,null,null,null,null,"その他(",null,null,null,null,null,null,null,null,")","○","不明"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"再発日",null,null,null,null,null,null,null,"その他(",null,null,null,null,null,null,null,null,")","○","不明"]
[null,null,null,null,null,null,null,null,null,"＊再摂取で症状再発「あり」の場合、その症状の詳細を記載してください。"]
[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,"□","摂取量 減量",null,null,null,null,"→",null,"減量後に症状改善：",null,null,null,null,null,null,"○","あり",null,null,"○","なし",null,null,null,null,null,"○","不明"]
[null,null,null,null,null,null,null,"□","摂取量 増量",null,null,null,null,"→",null,"増量後に症状悪化：",null,null,null,null,null,null,"○","あり",null,null,"○","なし",null,null,null,null,null,"○","不明"]
[null,null,null,null,null,null,null,null,null,"＊増量後に症状悪化「あり」の場合、その症状の詳細を記載してください。"]
[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,"□","継続",null,null,null,null,"→",null,"継続後の症状の変化：",null,null,null,null,null,null,"○","あり",null,null,"○","なし",null,null,null,null,null,"○","不明"]
[null,null,null,null,null,null,null,null,null,"＊症状の変化「あり」の場合、その詳細を記載してください。"]
[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,"□","不明"]
[" 1日摂取量",null,null,null,null,null,"　　　　","□","製品に表示されている摂取目安量のとおり"]
[null,null,null,null,null,null,null,"□","摂取目安量より少量",null,null,null,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,"　　　　","□","過量",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,"　　　　","□","その他",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,"　　　　　","□","不明"]
["基礎疾患・既往歴",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明"]
[null,null,null,null,null,null,"　ありの場合："]
[null,null,null,null,null,null,null,"□","高血圧症",null,null,null,null,"□","糖尿病",null,null,null,null,"□","脂質異常症",null,null,null,null,null,null,null,"□","胃腸疾患"]
[null,null,null,null,null,null,null,"□","腎臓病",null,null,null,null,"□","肝臓病",null,null,null,null,"□","心臓病(高血圧症を除く)",null,null,null,null,null,null,null,"□","呼吸器疾患"]
[null,null,null,null,null,null,null,"□","血液疾患",null,null,null,null,"□","膠原病・自己免疫疾患",null,null,null,null,null,null,null,null,null,null,null,null,null,"□","がん(部位：",null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","その他及び上記選択肢の詳細情報：病名を下記に記載して下さい。"]
[null,null,null,null,null,null,1]
[null,null,null,null,null,null,2]
[null,null,null,null,null,null,3]
[null,null,null,null,null,null,4]
[null,null,null,null,null,null,5]
["アレルギーの有無",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明"]
[null,null,null,null,null,null,"　ありの場合："]
[null,null,null,null,null,null,null,"□","薬アレルギー（薬の種類：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"□","食物アレルギー（食品の種類：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"□","接触アレルギー(アレルギー源：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,"□","季節性アレルギー/花粉症等(アレルギー源：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","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,"）"]
["妊娠の有無",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明",null,null,null,"※女性の場合のみ選択してください"]
["授乳の有無",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明",null,null,null,"※女性の場合のみ選択してください"]
["併用している\n医薬品",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明"]
["ある場合",null,null,null,"医薬品名",null,null,null,null,null,null,null,null,null,null,null,null,"使用目的",null,null,null,null,null,null,null,null,null,null,null,null,"使用開始日"]
[null,1]
[null,2]
[null,3]
[null,4]
[null,5]
[null,6]
[null,7]
[null,8]
[null,9]
[null,10]
[null,11]
[null,12]
[null,13]
[null,14]
[null,15]
["  併用している他の健康食品",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明"]
["ある場合",null,null,null,"製品名",null,null,null,null,null,null,null,null,"製造者名等",null,null,null,null,null,null,null,null,"摂取目的",null,null,null,null,null,null,null,"摂取開始日"]
[null,1]
[null,2]
[null,3]
[null,4]
[null,5]
[null,6]
[null,7]
[null,8]
[null,9]
[null,10]
[]
["３．受診情報"]
["医療機関受診",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明"]
[null,"＊ 今回の症状のために受診した医療機関\n(３つ以上ある場合は「６．その他」の備考欄に記載）",null,null,null,null," 医療機関名・診療科：",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,"○","不明"]
[null,null,null,null,null,null," 所在地：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
[null,null,null,null,null,null," 受診日：",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,"○","不明"]
[null,null,null,null,null,null,"受診理由：",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,"○","不明"]
[null,null,null,null,null,null," 医療機関名・診療科：",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,"○","不明"]
[null,null,null,null,null,null," 所在地：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
[null,null,null,null,null,null," 受診日：",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,"○","不明"]
[null,null,null,null,null,null,"受診理由：",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,"○","不明"]
["その他の医療機関\n（かかりつけ病院）",null,null,null,null,null," 医療機関名・診療科：",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,"○","不明"]
[null,null,null,null,null,null," 所在地：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"○","不明"]
["重篤度",null,null,null,null,null,null,null,"○","軽微",null,null,null,null,"○","軽度",null,null,null,null,"○","中等度以上",null,null,null,null,"○","死亡",null,null,null,null,null,"○","不明"]
["重篤度の記載については、次の①から④までを参考に記入すること。ただし、入院治療を受けた場合であって、医師が重篤ではないと判断した症例は、②として取り扱い、一方で、入院治療を受けていない場合であって、医師が重篤と判断した症例は、③として取り扱う。\n\n①軽　微：摂取者が、医療機関を受診していない場合又は医療機関を受診したが治療を受けなかった場合\n②軽　度：摂取者が、医療機関において外来治療を受けた場合(入院治療を受けた場合を除く)\n③中等度以上：摂取者が、医療機関において入院治療を受けた場合\n④死　亡：摂取者が、死亡した場合"]
["転帰",null,null,null,null,null,null,"○","自然治癒",null,null,null,"○","外来治療で治癒",null,null,null,null,null,"○","入院治療で治癒",null,null,null,null,null,"○","未回復",null,null,null,null,null,"○","不明"]
[]
["４．医師の診断結果"]
["医師への聞き取り",null,null,null,null,null,null,"○","あり",null,null,"○","なし（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,"　ありの場合："]
[null,null,null,null,null,null,"聞き取り日",null,null,null,null,null,null,null,null,"医療機関情報"]
["         症状",null,null,null,null,null,null,null,null,"詳細（診断名等）"]
["聞き取りがある場合(複数選択可)","主\nな\n症\n状",null,"□","皮膚症状"]
[null,null,null,"□","消化器症状"]
[null,null,null,"□","肝機能障害"]
[null,null,null,"□","腎機能障害"]
[null,null,null,"□","呼吸器障害"]
[null,null,null,"□","循環器障害"]
[null,null,null,"□","神経障害"]
[null,null,null,"□","血液障害"]
[null,null,null,"□","その他"]
[null,"そ\nの\n他\nの\n症\n状",null,"□","皮膚症状"]
[null,null,null,"□","消化器症状"]
[null,null,null,"□","肝機能障害"]
[null,null,null,"□","腎機能障害"]
[null,null,null,"□","呼吸器障害"]
[null,null,null,"□","循環器障害"]
[null,null,null,"□","神経障害"]
[null,null,null,"□","血液障害"]
[null,null,null,"□","その他"]
["臨床検査実施の有無"]
[null,null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明"]
[null,null,null,null,null,null," ありの場合："]
[null,null,null,null,null,null,null,"○","異常あり",null,null,null,"○","異常なし",null,null,null,"○","不明"]
["検査ありの場合\nその詳細\n（臨床検査値の異常の他、DLST等の検査結果がある場合も記載ください）"]
[]
[]
["健康被害の症状の発現及び処置後の経過"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,"＊健康食品との関連が疑われる健康被害について、関連する状態・症状、検査値等の推移、診断の根拠、治療・処置等を経時的に記載してください。"]
[]
["医師の意見等"]
[]
[]
[]
[]
["５．届出状況"]
["情報提供者が報告者以外へ報告しているか",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし",null,null,null,"○","不明"]
["ある場合その報告先",null,null,null,null,null,null,"□","事業者（販売者、製造者等）",null,null,null,null,null,null,null,null,null,null,"(事業者名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,null,null,null,"□","自治体(自治体名：",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,"□","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,"）"]
[]
["６．その他"]
["備考欄\n（消費/賞味期限切れ、保存状態の不備等に関する補足情報や、本様式に該当箇所がないものの特記すべきが望ましいと判断される情報等（詳細な症状経過等、死因（死亡事例の場合）、医薬品成分等の分析結果(※)等）あれば、こちらに記載してください）\n\n※「７．添付ファイル」に資料を添付することで記載省略可"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["添付資料の有無",null,null,null,null,null,null,"○","あり",null,null,null,"○","なし"]
[]
["７．添付ファイル"]
["原材料名・\n含有量・配合量"]
["その他添付資料①"]
["その他添付資料②"]
["その他添付資料③"]
["その他添付資料④"]
["その他添付資料⑤"]
[]
["注１）事業者におかれては、情報収集している主治医に対して、保健所から血液検査結果、カルテ、退院サマリー等の医療情報の提供依頼が来る可能性があることをお伝えいただけると幸いです。\n注２）都道府県等（保健所）におかれては、摂取者の了承のもと医療機関から医療情報を入手された場合は、氏名・連絡先をマスキングしたうえで当該データを添付いただけると幸いです。"]
[]
[]
["＜行政コメント・資料欄＞"]

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["年","月","ラジオ","チェック","消費/賞味","年齢","摂取後","パターン"]
[2020,1,"○","□","▼選択▼","▼選択▼","▼選択▼","-"]
[2021,2,"●","■","消費期限","歳","時間","入力"]
[2022,3,null,null,"賞味期限","歳代","日","選択"]
[2023,4,null,null,null,null,null,"フラグ"]
[2024,5,null,null,null,null,null,"ドロップ"]
[2025,6,null,null,null,null,null,"ファイル"]
[2026,7]
[2027,8]
[2028,9]
[2029,10]
[2030,11]
[2031,12]
[2032]
[2033]
[2034]
[2035]
[2036]
[2037]
[2038]
[2039]
[2040]
[2041]
[2042]
[2043]
[2044]
[2045]
[2046]
[2047]
[2048]
[2049]
[2050]

{"sheet":"csvdata","index":3,"n_rows":1,"n_cols":1,"rows_kept":1,"cut":false,"hidden":true,"merged":[]}
[""]