{"id":5552,"date":"2024-11-25T23:09:34","date_gmt":"2024-11-25T15:09:34","guid":{"rendered":"https:\/\/health.exebrain.com\/?page_id=5552"},"modified":"2024-12-13T00:55:41","modified_gmt":"2024-12-12T16:55:41","slug":"exebrain-form","status":"publish","type":"page","link":"https:\/\/health.exebrain.com\/en\/exebrain-form\/","title":{"rendered":"Assessment"},"content":{"rendered":"<div class='fluentform ff-default fluentform_wrapper_6  ff_guten_block ff_guten_block-6 ffs_custom_wrap'><form data-form_id=\"6\" id=\"fluentform_6\" class=\"frm-fluent-form fluent_form_6 ff-el-form-top ff_form_instance_6_1 ff-form-loading ffs_custom\" data-form_instance=\"ff_form_instance_6_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">\u7dda\u4e0a\u8a55\u91cf<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='5552' \/><input type=\"hidden\" id=\"_fluentform_6_fluentformnonce\" name=\"_fluentform_6_fluentformnonce\" value=\"f6ab4ff4c3\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/5552\" \/><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_input_text' id='label_ff_6_input_text'>\u59d3\u540d(\u4e2d\u6587\u5168\u540d)<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_6_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u6027\u5225<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_d55ed7509b31cec7380a0601345ae82e'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u7537\"  id='input_radio_d55ed7509b31cec7380a0601345ae82e' aria-label='\u7537' aria-invalid='false' aria-required=true> <span>\u7537<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_639b05452270e322d8c742a28865715a'><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5973\"  id='input_radio_639b05452270e322d8c742a28865715a' aria-label='\u5973' aria-invalid='false' aria-required=true> <span>\u5973<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u5e74\u9f61<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_3c7efa46df756975fac0fe2e6e5b57e1'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"20\u6b72\u4ee5\u4e0b\"  id='input_radio_1_3c7efa46df756975fac0fe2e6e5b57e1' aria-label='20\u6b72\u4ee5\u4e0b' aria-invalid='false' aria-required=true> <span>20\u6b72\u4ee5\u4e0b<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_2fd3703c1f0532df9ac10304ee4989ca'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"21-34\u6b72\"  id='input_radio_1_2fd3703c1f0532df9ac10304ee4989ca' aria-label='21-34\u6b72' aria-invalid='false' aria-required=true> <span>21-34\u6b72<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_1f0ddf5e03a26be29fbedd86ff7f4b54'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"35-50\u6b72\"  id='input_radio_1_1f0ddf5e03a26be29fbedd86ff7f4b54' aria-label='35-50\u6b72' aria-invalid='false' aria-required=true> <span>35-50\u6b72<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_2e3326b69858fcf4c439b261af0abb64'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"51-64\u6b72\"  id='input_radio_1_2e3326b69858fcf4c439b261af0abb64' aria-label='51-64\u6b72' aria-invalid='false' aria-required=true> <span>51-64\u6b72<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_1_e752f8a16aa143dcb48ef90b31268357'><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"65\u6b72\u4ee5\u4e0a\"  id='input_radio_1_e752f8a16aa143dcb48ef90b31268357' aria-label='65\u6b72\u4ee5\u4e0a' aria-invalid='false' aria-required=true> <span>65\u6b72\u4ee5\u4e0a<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u5c45\u4f4f\u5730\u00a0(\u6613\u601d\u8166\u5ba2\u88fd\u5316\u5be6\u9ad4\u8ab2\u7a0b\u64da\u9ede\u4f4d\u65bc\u53f0\u5317\u5167\u6e56)<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_bad8020d316b375119f5c1f2293bd5fa'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5317\u5317\u57fa\"  id='input_radio_14_bad8020d316b375119f5c1f2293bd5fa' aria-label='\u5317\u5317\u57fa' aria-invalid='false' aria-required=true> <span>\u5317\u5317\u57fa<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_33d6cad1a4435e6e5b564f414cfc233f'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u65b0\u7af9\"  id='input_radio_14_33d6cad1a4435e6e5b564f414cfc233f' aria-label='\u65b0\u7af9' aria-invalid='false' aria-required=true> <span>\u65b0\u7af9<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_a9374a7ddc56a807d71b8ac31cae3b0f'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u6843\u5712\"  id='input_radio_14_a9374a7ddc56a807d71b8ac31cae3b0f' aria-label='\u6843\u5712' aria-invalid='false' aria-required=true> <span>\u6843\u5712<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_67b842375cade44ae0eb43910907d037'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u4e2d\u90e8\"  id='input_radio_14_67b842375cade44ae0eb43910907d037' aria-label='\u4e2d\u90e8' aria-invalid='false' aria-required=true> <span>\u4e2d\u90e8<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_0e55026524c2261cf48e5bd52995cbbc'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5357\u90e8\"  id='input_radio_14_0e55026524c2261cf48e5bd52995cbbc' aria-label='\u5357\u90e8' aria-invalid='false' aria-required=true> <span>\u5357\u90e8<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_7032be829b6c6b08381060ae21e23bc7'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u6771\u90e8\"  id='input_radio_14_7032be829b6c6b08381060ae21e23bc7' aria-label='\u6771\u90e8' aria-invalid='false' aria-required=true> <span>\u6771\u90e8<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_a437c77dfa4a20467f827b3983bab8e9'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u96e2\u5cf6\"  id='input_radio_14_a437c77dfa4a20467f827b3983bab8e9' aria-label='\u96e2\u5cf6' aria-invalid='false' aria-required=true> <span>\u96e2\u5cf6<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_14_4d781a5c5ab305354d121df584d1ca0c'><input  type=\"radio\" name=\"input_radio_14\" data-name=\"input_radio_14\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5176\u4ed6\"  id='input_radio_14_4d781a5c5ab305354d121df584d1ca0c' aria-label='\u5176\u4ed6' aria-invalid='false' aria-required=true> <span>\u5176\u4ed6<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_input_text_4' id='label_ff_6_input_text_4'>\u5c45\u4f4f\u5730\uff5c\u5176\u4ed6<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" placeholder=\"\u8acb\u586b\u5beb\u60a8\u7684\u5c45\u4f4f\u5730\" data-name=\"input_text_4\" id=\"ff_6_input_text_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u5de5\u4f5c\u7522\u696d\u5225<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_fa2e4ae022840b5b689e6ef4b8b3a28b'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u4e0a\u73ed\u65cf\"  id='input_radio_2_fa2e4ae022840b5b689e6ef4b8b3a28b' aria-label='\u4e0a\u73ed\u65cf' aria-invalid='false' aria-required=true> <span>\u4e0a\u73ed\u65cf<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_e72c5901f34fcb553b2c978efd4aa19a'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5546\u696d\"  id='input_radio_2_e72c5901f34fcb553b2c978efd4aa19a' aria-label='\u5546\u696d' aria-invalid='false' aria-required=true> <span>\u5546\u696d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_7285bc78d50eae416e5b59b7cb4ff629'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u670d\u52d9\u696d\"  id='input_radio_2_7285bc78d50eae416e5b59b7cb4ff629' aria-label='\u670d\u52d9\u696d' aria-invalid='false' aria-required=true> <span>\u670d\u52d9\u696d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_d262ff2a208fa9608cf43a21a9765ca8'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u8cc7\u8a0a\u696d\"  id='input_radio_2_d262ff2a208fa9608cf43a21a9765ca8' aria-label='\u8cc7\u8a0a\u696d' aria-invalid='false' aria-required=true> <span>\u8cc7\u8a0a\u696d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_b003a5062952cc6401fedb0f35347c0e'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u88fd\u9020\u696d\"  id='input_radio_2_b003a5062952cc6401fedb0f35347c0e' aria-label='\u88fd\u9020\u696d' aria-invalid='false' aria-required=true> <span>\u88fd\u9020\u696d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_6845743d29235f4bc08849e107f93c47'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u904b\u52d5\u54e1\"  id='input_radio_2_6845743d29235f4bc08849e107f93c47' aria-label='\u904b\u52d5\u54e1' aria-invalid='false' aria-required=true> <span>\u904b\u52d5\u54e1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_2da5a3f16e1d41a41d5d96d1d54a314b'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u8ecd\u3001\u516c\u3001\u6559\"  id='input_radio_2_2da5a3f16e1d41a41d5d96d1d54a314b' aria-label='\u8ecd\u3001\u516c\u3001\u6559' aria-invalid='false' aria-required=true> <span>\u8ecd\u3001\u516c\u3001\u6559<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_98d682f0f340ec18498997828e0b8b34'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u8fb2\u6797\u6f01\u7267\u696d\"  id='input_radio_2_98d682f0f340ec18498997828e0b8b34' aria-label='\u8fb2\u6797\u6f01\u7267\u696d' aria-invalid='false' aria-required=true> <span>\u8fb2\u6797\u6f01\u7267\u696d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_53e94673bafcf214c24acef6708e5c19'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u91ab\u7642\u4fdd\u5065\u696d\"  id='input_radio_2_53e94673bafcf214c24acef6708e5c19' aria-label='\u91ab\u7642\u4fdd\u5065\u696d' aria-invalid='false' aria-required=true> <span>\u91ab\u7642\u4fdd\u5065\u696d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_eb22436bbb2e1035ae0351ff45df0954'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5ee3\u544a\u5a92\u9ad4\u696d\"  id='input_radio_2_eb22436bbb2e1035ae0351ff45df0954' aria-label='\u5ee3\u544a\u5a92\u9ad4\u696d' aria-invalid='false' aria-required=true> <span>\u5ee3\u544a\u5a92\u9ad4\u696d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_bd9323ed4723f1b2ff0d7f1c002df6bc'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5bb6\u7ba1\"  id='input_radio_2_bd9323ed4723f1b2ff0d7f1c002df6bc' aria-label='\u5bb6\u7ba1' aria-invalid='false' aria-required=true> <span>\u5bb6\u7ba1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_d3bfe55e559a8e59c51d77f3fda6577c'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5b78\u751f\"  id='input_radio_2_d3bfe55e559a8e59c51d77f3fda6577c' aria-label='\u5b78\u751f' aria-invalid='false' aria-required=true> <span>\u5b78\u751f<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_2_cc7d6f5ab2a0a1221407e4357509daf2'><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5176\u4ed6\"  id='input_radio_2_cc7d6f5ab2a0a1221407e4357509daf2' aria-label='\u5176\u4ed6' aria-invalid='false' aria-required=true> <span>\u5176\u4ed6<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_input_text_1' id='label_ff_6_input_text_1'>\u5de5\u4f5c\u8077\u7a31<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_6_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u60a8\u81ea\u89ba\u6709\u54ea\u4e9b\u56f0\u64fe\uff1f\uff08\u53ef\u8907\u9078\uff09<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_98a5f7ba211cba4e52ab405a5692eb87'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u7761\u7720\u969c\u7919\"  id='checkbox_98a5f7ba211cba4e52ab405a5692eb87' aria-label='\u7761\u7720\u969c\u7919' aria-invalid='false' aria-required=true> <span>\u7761\u7720\u969c\u7919<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_5287388b618fbb12cdee4de1bf26c186'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u8a18\u61b6\u529b\u8870\u9000\"  id='checkbox_5287388b618fbb12cdee4de1bf26c186' aria-label='\u8a18\u61b6\u529b\u8870\u9000' aria-invalid='false' aria-required=true> <span>\u8a18\u61b6\u529b\u8870\u9000<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8d9ea08b472fb9c84224a6eb84743851'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u6ce8\u610f\u529b\u4e0d\u8db3\"  id='checkbox_8d9ea08b472fb9c84224a6eb84743851' aria-label='\u6ce8\u610f\u529b\u4e0d\u8db3' aria-invalid='false' aria-required=true> <span>\u6ce8\u610f\u529b\u4e0d\u8db3<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_f23d2871d5a430c28707c60d5790c60f'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u60c5\u7dd2\u9ad8\u4f4e\u4e0d\u7a69\u5b9a\"  id='checkbox_f23d2871d5a430c28707c60d5790c60f' aria-label='\u60c5\u7dd2\u9ad8\u4f4e\u4e0d\u7a69\u5b9a' aria-invalid='false' aria-required=true> <span>\u60c5\u7dd2\u9ad8\u4f4e\u4e0d\u7a69\u5b9a<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_aa492692a3bb8910cbf7393829ef3a2e'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u58d3\u529b\u578b\u982d\u75db\u3001\u504f\u982d\u75db\"  id='checkbox_aa492692a3bb8910cbf7393829ef3a2e' aria-label='\u58d3\u529b\u578b\u982d\u75db\u3001\u504f\u982d\u75db' aria-invalid='false' aria-required=true> <span>\u58d3\u529b\u578b\u982d\u75db\u3001\u504f\u982d\u75db<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_cbbd9eff75c85b192d8a3ea3b0f5f763'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u4e2d\u98a8\u3001\u8166\u50b7\u3001\u5176\u4ed6\"  id='checkbox_cbbd9eff75c85b192d8a3ea3b0f5f763' aria-label='\u4e2d\u98a8\u3001\u8166\u50b7\u3001\u5176\u4ed6' aria-invalid='false' aria-required=true> <span>\u4e2d\u98a8\u3001\u8166\u50b7\u3001\u5176\u4ed6<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_abe27135bebab9cecf8f5cd6972417e3'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u5fc3\u60b8\u3001\u751f\u7406\u4e0d\u9069\"  id='checkbox_abe27135bebab9cecf8f5cd6972417e3' aria-label='\u5fc3\u60b8\u3001\u751f\u7406\u4e0d\u9069' aria-invalid='false' aria-required=true> <span>\u5fc3\u60b8\u3001\u751f\u7406\u4e0d\u9069<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_6bf2525d0960a8c86f28138e0f12401e'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u8166\u529b\u4e0d\u582a\u8ca0\u8377\u3001\u4e2d\u9ad8\u968e\u7d93\u7406\u4eba\u3001\u5c08\u696d\u8077\u80fd\"  id='checkbox_6bf2525d0960a8c86f28138e0f12401e' aria-label='\u8166\u529b\u4e0d\u582a\u8ca0\u8377\u3001\u4e2d\u9ad8\u968e\u7d93\u7406\u4eba\u3001\u5c08\u696d\u8077\u80fd' aria-invalid='false' aria-required=true> <span>\u8166\u529b\u4e0d\u582a\u8ca0\u8377\u3001\u4e2d\u9ad8\u968e\u7d93\u7406\u4eba\u3001\u5c08\u696d\u8077\u80fd<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_8a5374f7ca5672bf3b65095b01e711b1'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u66f4\u5e74\u671f\u4e0d\u9069\"  id='checkbox_8a5374f7ca5672bf3b65095b01e711b1' aria-label='\u66f4\u5e74\u671f\u4e0d\u9069' aria-invalid='false' aria-required=true> <span>\u66f4\u5e74\u671f\u4e0d\u9069<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3a9c60b92a24102c783285fca9d98b20'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u4ee5\u4e0a\u7686\u7121\"  id='checkbox_3a9c60b92a24102c783285fca9d98b20' aria-label='\u4ee5\u4e0a\u7686\u7121' aria-invalid='false' aria-required=true> <span>\u4ee5\u4e0a\u7686\u7121<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_9e8f7b6cf4635ce4f86cbc4f8000690c'><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u5176\u4ed6\"  id='checkbox_9e8f7b6cf4635ce4f86cbc4f8000690c' aria-label='\u5176\u4ed6' aria-invalid='false' aria-required=true> <span>\u5176\u4ed6<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_input_text_2' id='label_ff_6_input_text_2'>\u60a8\u81ea\u89ba\u6709\u54ea\u4e9b\u56f0\u64fe\uff1f\uff08\u5176\u4ed6\uff09<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_6_input_text_2\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u4ee5\u4e0b\u54ea\u4e9b\u7b26\u5408\u60a8\u9019\u4e00\u500b\u6708\u7684\u8fd1\u6cc1\uff1f\uff08\u53ef\u8907\u9078\uff09<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_757df986f550b7428161d853b13c0d77'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u5fc3\u88e1\u60f3\u505a\u67d0\u4e8b\uff0c\u529b\u91cf\u537b\u7121\u6cd5\u9054\u5230\"  id='checkbox_1_757df986f550b7428161d853b13c0d77' aria-label='\u5fc3\u88e1\u60f3\u505a\u67d0\u4e8b\uff0c\u529b\u91cf\u537b\u7121\u6cd5\u9054\u5230' aria-invalid='false' aria-required=true> <span>\u5fc3\u88e1\u60f3\u505a\u67d0\u4e8b\uff0c\u529b\u91cf\u537b\u7121\u6cd5\u9054\u5230<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_341a5f87706f80bbf17c67f8ab396b5f'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u5c0d\u74b0\u5883\u7f3a\u4e4f\u63a7\u5236\u611f\uff0c\u89ba\u5f97\u81ea\u5df1\u904e\u5f80\u7684\u80fd\u529b\u4e0d\u518d\u3001\u5de5\u4f5c\u8868\u73fe\u53cd\u61c9\u50f5\u5316\"  id='checkbox_1_341a5f87706f80bbf17c67f8ab396b5f' aria-label='\u5c0d\u74b0\u5883\u7f3a\u4e4f\u63a7\u5236\u611f\uff0c\u89ba\u5f97\u81ea\u5df1\u904e\u5f80\u7684\u80fd\u529b\u4e0d\u518d\u3001\u5de5\u4f5c\u8868\u73fe\u53cd\u61c9\u50f5\u5316' aria-invalid='false' aria-required=true> <span>\u5c0d\u74b0\u5883\u7f3a\u4e4f\u63a7\u5236\u611f\uff0c\u89ba\u5f97\u81ea\u5df1\u904e\u5f80\u7684\u80fd\u529b\u4e0d\u518d\u3001\u5de5\u4f5c\u8868\u73fe\u53cd\u61c9\u50f5\u5316<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_afe0bb642db3398848e90921ddad5005'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u300c\u6c92\u6709\u7279\u5b9a\u539f\u56e0\u300d\u537b\u7dca\u5f35\uff0c\u5c0e\u81f4\u7121\u6cd5\u96c6\u4e2d\u6ce8\u610f\u529b\uff0c\u89ba\u5f97\u4e00\u4e8b\u7121\u6210\"  id='checkbox_1_afe0bb642db3398848e90921ddad5005' aria-label='\u300c\u6c92\u6709\u7279\u5b9a\u539f\u56e0\u300d\u537b\u7dca\u5f35\uff0c\u5c0e\u81f4\u7121\u6cd5\u96c6\u4e2d\u6ce8\u610f\u529b\uff0c\u89ba\u5f97\u4e00\u4e8b\u7121\u6210' aria-invalid='false' aria-required=true> <span>\u300c\u6c92\u6709\u7279\u5b9a\u539f\u56e0\u300d\u537b\u7dca\u5f35\uff0c\u5c0e\u81f4\u7121\u6cd5\u96c6\u4e2d\u6ce8\u610f\u529b\uff0c\u89ba\u5f97\u4e00\u4e8b\u7121\u6210<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_395a8692ade0501fd3c9f0782b887c6d'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u5fd8\u8a18\u91cd\u8981\u7684\u7d04\u6703\u3001\u66fe\u7d93\u904e\u7684\u5c0d\u8a71\u6216\u662f\u6700\u8fd1\u767c\u751f\u7684\u4e8b\u4ef6\"  id='checkbox_1_395a8692ade0501fd3c9f0782b887c6d' aria-label='\u5fd8\u8a18\u91cd\u8981\u7684\u7d04\u6703\u3001\u66fe\u7d93\u904e\u7684\u5c0d\u8a71\u6216\u662f\u6700\u8fd1\u767c\u751f\u7684\u4e8b\u4ef6' aria-invalid='false' aria-required=true> <span>\u5fd8\u8a18\u91cd\u8981\u7684\u7d04\u6703\u3001\u66fe\u7d93\u904e\u7684\u5c0d\u8a71\u6216\u662f\u6700\u8fd1\u767c\u751f\u7684\u4e8b\u4ef6<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_e95d1791487a7912340f0dd8087437b4'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u89ba\u5f97\u81ea\u5df1\u7684\u5de5\u4f5c\u8207\u793e\u4ea4\u80fd\u529b\u4e0b\u964d\"  id='checkbox_1_e95d1791487a7912340f0dd8087437b4' aria-label='\u89ba\u5f97\u81ea\u5df1\u7684\u5de5\u4f5c\u8207\u793e\u4ea4\u80fd\u529b\u4e0b\u964d' aria-invalid='false' aria-required=true> <span>\u89ba\u5f97\u81ea\u5df1\u7684\u5de5\u4f5c\u8207\u793e\u4ea4\u80fd\u529b\u4e0b\u964d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_f53b0b4da9c1dbd1f59fa14dd18cb055'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u95b1\u8b80\u7406\u89e3\u7684\u80fd\u529b\u4e0b\u964d\"  id='checkbox_1_f53b0b4da9c1dbd1f59fa14dd18cb055' aria-label='\u95b1\u8b80\u7406\u89e3\u7684\u80fd\u529b\u4e0b\u964d' aria-invalid='false' aria-required=true> <span>\u95b1\u8b80\u7406\u89e3\u7684\u80fd\u529b\u4e0b\u964d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_1e723a95b8947670f942cbff2043e0ab'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u8868\u9054\u60f3\u6cd5\u3001\u8aaa\u660e\u4e8b\u60c5\u7684\u80fd\u529b\u4e0b\u964d\"  id='checkbox_1_1e723a95b8947670f942cbff2043e0ab' aria-label='\u8868\u9054\u60f3\u6cd5\u3001\u8aaa\u660e\u4e8b\u60c5\u7684\u80fd\u529b\u4e0b\u964d' aria-invalid='false' aria-required=true> <span>\u8868\u9054\u60f3\u6cd5\u3001\u8aaa\u660e\u4e8b\u60c5\u7684\u80fd\u529b\u4e0b\u964d<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_0e3c5dfa02e989b0f851d5c76252df13'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u4ee5\u4e0a\u7686\u7121\"  id='checkbox_1_0e3c5dfa02e989b0f851d5c76252df13' aria-label='\u4ee5\u4e0a\u7686\u7121' aria-invalid='false' aria-required=true> <span>\u4ee5\u4e0a\u7686\u7121<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_1_1ef582756401999a3f12553391c6efe9'><input  type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u5176\u4ed6\"  id='checkbox_1_1ef582756401999a3f12553391c6efe9' aria-label='\u5176\u4ed6' aria-invalid='false' aria-required=true> <span>\u5176\u4ed6<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_input_text_3' id='label_ff_6_input_text_3'>\u4ee5\u4e0b\u54ea\u4e9b\u7b26\u5408\u60a8\u9019\u4e00\u500b\u6708\u7684\u8fd1\u6cc1\uff1f\uff08\u5176\u4ed6\uff09<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_6_input_text_3\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u60a8\u662f\u5426\u66fe\u7d93\u524d\u5f80\u8eab\u5fc3\u79d1\u3001\u795e\u7d93\u79d1\u5c31\u8a3a\uff1f<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_d10b9aed97776478e17972ec9010c378'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u7121\"  id='input_radio_3_d10b9aed97776478e17972ec9010c378' aria-label='\u7121' aria-invalid='false' aria-required=true> <span>\u7121<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_851ccf94c78e0de2c815a7674a129c46'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u6709\uff0c\u4f46\u5df2\u505c\u6b62\u56de\u8a3a\u81f3\u5c11\u534a\u5e74\u4ee5\u4e0a\"  id='input_radio_3_851ccf94c78e0de2c815a7674a129c46' aria-label='\u6709\uff0c\u4f46\u5df2\u505c\u6b62\u56de\u8a3a\u81f3\u5c11\u534a\u5e74\u4ee5\u4e0a' aria-invalid='false' aria-required=true> <span>\u6709\uff0c\u4f46\u5df2\u505c\u6b62\u56de\u8a3a\u81f3\u5c11\u534a\u5e74\u4ee5\u4e0a<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_3_36b1385f963a6ab949f4f482fda4ffc7'><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u6709\uff0c\u76ee\u524d\u4ecd\u6301\u7e8c\u56de\u8a3a\u4e2d\"  id='input_radio_3_36b1385f963a6ab949f4f482fda4ffc7' aria-label='\u6709\uff0c\u76ee\u524d\u4ecd\u6301\u7e8c\u56de\u8a3a\u4e2d' aria-invalid='false' aria-required=true> <span>\u6709\uff0c\u76ee\u524d\u4ecd\u6301\u7e8c\u56de\u8a3a\u4e2d<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u60a8\u66fe\u7d93\u505a\u904e\u54ea\u4e9b\u8a55\u4f30\u982d\u90e8\u5065\u5eb7\u7684\u6aa2\u67e5\uff1f\uff08\u53ef\u8907\u9078\uff09<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_e204265ac32bc371531ffeab55f52544'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u8166\u6ce2\u6aa2\u67e5\"  id='checkbox_2_e204265ac32bc371531ffeab55f52544' aria-label='\u8166\u6ce2\u6aa2\u67e5' aria-invalid='false' aria-required=true> <span>\u8166\u6ce2\u6aa2\u67e5<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_9d9b1778a8889fe8e4f774fa5244fd89'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u96fb\u8166\u65b7\u5c64\u6383\u63cf(CT)\u6aa2\u67e5\"  id='checkbox_2_9d9b1778a8889fe8e4f774fa5244fd89' aria-label='\u96fb\u8166\u65b7\u5c64\u6383\u63cf(CT)\u6aa2\u67e5' aria-invalid='false' aria-required=true> <span>\u96fb\u8166\u65b7\u5c64\u6383\u63cf(CT)\u6aa2\u67e5<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_6e6b30978f24b47e20ca99674c50e78f'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u6838\u78c1\u5171\u632f\u9020\u5f71(MRI)\u6aa2\u67e5\"  id='checkbox_2_6e6b30978f24b47e20ca99674c50e78f' aria-label='\u6838\u78c1\u5171\u632f\u9020\u5f71(MRI)\u6aa2\u67e5' aria-invalid='false' aria-required=true> <span>\u6838\u78c1\u5171\u632f\u9020\u5f71(MRI)\u6aa2\u67e5<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_2_29649d9200c1051f1398df83f894c353'><input  type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u4ee5\u4e0a\u7686\u7121\"  id='checkbox_2_29649d9200c1051f1398df83f894c353' aria-label='\u4ee5\u4e0a\u7686\u7121' aria-invalid='false' aria-required=true> <span>\u4ee5\u4e0a\u7686\u7121<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u60a8\u904e\u53bb\u6216\u73fe\u5728\u662f\u5426\u6b63\u5728\u670d\u85e5\uff1f<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_51bc28561e040d868fd983eb14c3b8e0'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u6c92\u6709\"  id='input_radio_4_51bc28561e040d868fd983eb14c3b8e0' aria-label='\u6c92\u6709' aria-invalid='false' aria-required=true> <span>\u6c92\u6709<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_cc8b8b7a9d853739327dfadce771777b'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u904e\u53bb\u6709\uff0c\u73fe\u5df2\u505c\u85e5\u3002\"  id='input_radio_4_cc8b8b7a9d853739327dfadce771777b' aria-label='\u904e\u53bb\u6709\uff0c\u73fe\u5df2\u505c\u85e5\u3002' aria-invalid='false' aria-required=true> <span>\u904e\u53bb\u6709\uff0c\u73fe\u5df2\u505c\u85e5\u3002<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_4_6374d3e71a9fdb51c1f3f3aef5551dc5'><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u73fe\u5728\u6709\u670d\u85e5\"  id='input_radio_4_6374d3e71a9fdb51c1f3f3aef5551dc5' aria-label='\u73fe\u5728\u6709\u670d\u85e5' aria-invalid='false' aria-required=true> <span>\u73fe\u5728\u6709\u670d\u85e5<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u82e5\u6211\u5011\u6bd4\u55bb\u60a8\u76ee\u524d\u7684\u5927\u8166\u904b\u4f5c\u6548\u80fd\u5206\u6578\u662f50\u5206\uff0c\u60a8\u671f\u76fc\u5927\u8166\u935b\u934a\u5f8c\u53ef\u4ee5\u9032\u6b65\u5230\u5e7e\u5206\uff1f<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_82a8a62866b46ee3bfa2b88466acc932'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"60\u5206\"  id='input_radio_5_82a8a62866b46ee3bfa2b88466acc932' aria-label='60\u5206' aria-invalid='false' aria-required=true> <span>60\u5206<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_1db38265a63f88ca9d4272d573a985ec'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"70\u5206\"  id='input_radio_5_1db38265a63f88ca9d4272d573a985ec' aria-label='70\u5206' aria-invalid='false' aria-required=true> <span>70\u5206<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_47cabe4616497733531a0b6ca684f135'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"80\u5206\"  id='input_radio_5_47cabe4616497733531a0b6ca684f135' aria-label='80\u5206' aria-invalid='false' aria-required=true> <span>80\u5206<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_6f4657ac65ea05f92fd715b2656826a1'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"90\u5206\"  id='input_radio_5_6f4657ac65ea05f92fd715b2656826a1' aria-label='90\u5206' aria-invalid='false' aria-required=true> <span>90\u5206<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_5_9ea95d34e4a4363d8ccdb267a88ccdff'><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"99\u5206\"  id='input_radio_5_9ea95d34e4a4363d8ccdb267a88ccdff' aria-label='99\u5206' aria-invalid='false' aria-required=true> <span>99\u5206<\/span><\/label><\/div><\/div><\/div><div class=\"ff-el-group ff-el-section-break  ff_left\" data-name=\"section_break-6_1\" ><h3 class='ff-el-section-title'>\u7c21\u5f0f\u5065\u5eb7\u91cf\u8868<\/h3><div class='ff-section_break_desk'><p>\u8aaa\u660e\uff1a<br \/>\u672c\u91cf\u8868\u6240\u5217\u8209\u7684\u554f\u984c\u662f\u70ba\u5354\u52a9\u60a8\u77ad\u89e3\u60a8\u7684\u8eab\u5fc3\u9069\u61c9\u72c0\u6cc1\uff0c\u8acb\u60a8\u4ed4\u7d30\u56de\u60f3\u5728\u6700\u8fd1\u4e00\u661f\u671f\u4e2d(\u5305\u62ec\u4eca\u5929)\uff0c\u9019\u4e9b\u554f\u984c\u4f7f\u60a8\u611f\u5230\u56f0\u64fe\u6216\u82e6\u60f1\u7684\u7a0b\u5ea6\uff0c\u7136\u5f8c\u5708\u9078\u4e00\u500b\u60a8\u8a8d\u70ba\u6700\u80fd\u4ee3\u8868\u60a8\u611f\u89ba\u7684\u7b54\u6848\u3002<\/p>\n<div><br \/>\u8cc7\u6599\u53c3\u8003 :<br \/>\u570b\u7acb\u53f0\u5927\u91ab\u5b78\u9662\u7cbe\u795e\u79d1\u6559\u6388\u66a8\u7cbe\u795e\u90e8\u4e3b\u6cbb\u91ab\u5e2b \u674e\u660e\u6ff1\u91ab\u5e2b \u3002<\/div><\/div><hr \/><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >1. \u7761\u7720\u56f0\u96e3\uff0c\u8b6c\u5982\u96e3\u4ee5\u5165\u7761\u3001\u6613\u9192\u6216\u65e9\u9192\u3002<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_3b6778e858b47cacca64152c4044111b'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5b8c\u5168\u6c92\u6709\"  id='input_radio_7_3b6778e858b47cacca64152c4044111b' aria-label='\u5b8c\u5168\u6c92\u6709' aria-invalid='false' aria-required=true> <span>\u5b8c\u5168\u6c92\u6709<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_b7b306bff67e880790ad7023046913df'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u8f15\u5fae\"  id='input_radio_7_b7b306bff67e880790ad7023046913df' aria-label='\u8f15\u5fae' aria-invalid='false' aria-required=true> <span>\u8f15\u5fae<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_ddd4f54af1a84290fce3435431fd5788'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u4e2d\u7b49\u7a0b\u5ea6\"  id='input_radio_7_ddd4f54af1a84290fce3435431fd5788' aria-label='\u4e2d\u7b49\u7a0b\u5ea6' aria-invalid='false' aria-required=true> <span>\u4e2d\u7b49\u7a0b\u5ea6<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_ef846b4b919043eaee90bc9e13042c07'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5f37\u70c8\"  id='input_radio_7_ef846b4b919043eaee90bc9e13042c07' aria-label='\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u5f37\u70c8<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_7_bef8fcf8dc680a360731d2271e639484'><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u975e\u5e38\u5f37\u70c8\"  id='input_radio_7_bef8fcf8dc680a360731d2271e639484' aria-label='\u975e\u5e38\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u975e\u5e38\u5f37\u70c8<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >2. \u611f\u89ba\u7dca\u5f35\u4e0d\u5b89\u3002<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_b936e5c273d0c6d057f546315d252d4c'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5b8c\u5168\u6c92\u6709\"  id='input_radio_8_b936e5c273d0c6d057f546315d252d4c' aria-label='\u5b8c\u5168\u6c92\u6709' aria-invalid='false' aria-required=true> <span>\u5b8c\u5168\u6c92\u6709<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_6e3a125c143f59daf42e95d6494e4217'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u8f15\u5fae\"  id='input_radio_8_6e3a125c143f59daf42e95d6494e4217' aria-label='\u8f15\u5fae' aria-invalid='false' aria-required=true> <span>\u8f15\u5fae<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_9a7797e846d07f726dbb5dcd0d7ba063'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u4e2d\u7b49\u7a0b\u5ea6\"  id='input_radio_8_9a7797e846d07f726dbb5dcd0d7ba063' aria-label='\u4e2d\u7b49\u7a0b\u5ea6' aria-invalid='false' aria-required=true> <span>\u4e2d\u7b49\u7a0b\u5ea6<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_83249cda8c3afa2a0696a46f823a4139'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5f37\u70c8\"  id='input_radio_8_83249cda8c3afa2a0696a46f823a4139' aria-label='\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u5f37\u70c8<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_8_90f113f2b153aefca53e91af5d05b832'><input  type=\"radio\" name=\"input_radio_8\" data-name=\"input_radio_8\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u975e\u5e38\u5f37\u70c8\"  id='input_radio_8_90f113f2b153aefca53e91af5d05b832' aria-label='\u975e\u5e38\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u975e\u5e38\u5f37\u70c8<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >3. \u89ba\u5f97\u5bb9\u6613\u82e6\u60f1\u6216\u52d5\u6012\u3002<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_76a6c0f1ebbeb4cb89a781188d8fdd6b'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5b8c\u5168\u6c92\u6709\"  id='input_radio_9_76a6c0f1ebbeb4cb89a781188d8fdd6b' aria-label='\u5b8c\u5168\u6c92\u6709' aria-invalid='false' aria-required=true> <span>\u5b8c\u5168\u6c92\u6709<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_261cd45739225d625ae4184e777b1884'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u8f15\u5fae\"  id='input_radio_9_261cd45739225d625ae4184e777b1884' aria-label='\u8f15\u5fae' aria-invalid='false' aria-required=true> <span>\u8f15\u5fae<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_7b19bc8c0c236949d72921695fad1dfb'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u4e2d\u7b49\u7a0b\u5ea6\"  id='input_radio_9_7b19bc8c0c236949d72921695fad1dfb' aria-label='\u4e2d\u7b49\u7a0b\u5ea6' aria-invalid='false' aria-required=true> <span>\u4e2d\u7b49\u7a0b\u5ea6<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_ef70e77e7334a229ecadea0032016f38'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5f37\u70c8\"  id='input_radio_9_ef70e77e7334a229ecadea0032016f38' aria-label='\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u5f37\u70c8<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_9_ab0346b16931179b722a3e46cfba187b'><input  type=\"radio\" name=\"input_radio_9\" data-name=\"input_radio_9\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u975e\u5e38\u5f37\u70c8\"  id='input_radio_9_ab0346b16931179b722a3e46cfba187b' aria-label='\u975e\u5e38\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u975e\u5e38\u5f37\u70c8<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >4. \u611f\u89ba\u6182\u9b31\u3001\u5fc3\u60c5\u4f4e\u843d\u3002<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_bda43541cc9e21c6072b53a6e1ec0382'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5b8c\u5168\u6c92\u6709\"  id='input_radio_10_bda43541cc9e21c6072b53a6e1ec0382' aria-label='\u5b8c\u5168\u6c92\u6709' aria-invalid='false' aria-required=true> <span>\u5b8c\u5168\u6c92\u6709<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_0198e3917cb59d8980902fa58e8b059d'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u8f15\u5fae\"  id='input_radio_10_0198e3917cb59d8980902fa58e8b059d' aria-label='\u8f15\u5fae' aria-invalid='false' aria-required=true> <span>\u8f15\u5fae<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_9ed7d3fb45e96df5df004ee5bd9a3f86'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u4e2d\u7b49\u7a0b\u5ea6\"  id='input_radio_10_9ed7d3fb45e96df5df004ee5bd9a3f86' aria-label='\u4e2d\u7b49\u7a0b\u5ea6' aria-invalid='false' aria-required=true> <span>\u4e2d\u7b49\u7a0b\u5ea6<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_8f7dac2324b66605a023f73ffba37dde'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5f37\u70c8\"  id='input_radio_10_8f7dac2324b66605a023f73ffba37dde' aria-label='\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u5f37\u70c8<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_10_91bb91add25132505a2d1ebf63904448'><input  type=\"radio\" name=\"input_radio_10\" data-name=\"input_radio_10\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u975e\u5e38\u5f37\u70c8\"  id='input_radio_10_91bb91add25132505a2d1ebf63904448' aria-label='\u975e\u5e38\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u975e\u5e38\u5f37\u70c8<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >5. \u89ba\u5f97\u6bd4\u4e0d\u4e0a\u5225\u4eba\u3002<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_3b3e5b398085ee4b9b51c75e22104332'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5b8c\u5168\u6c92\u6709\"  id='input_radio_11_3b3e5b398085ee4b9b51c75e22104332' aria-label='\u5b8c\u5168\u6c92\u6709' aria-invalid='false' aria-required=true> <span>\u5b8c\u5168\u6c92\u6709<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_d0b54db4e090d3fdacce970d3756349f'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u8f15\u5fae\"  id='input_radio_11_d0b54db4e090d3fdacce970d3756349f' aria-label='\u8f15\u5fae' aria-invalid='false' aria-required=true> <span>\u8f15\u5fae<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_62a3394f284e13a1dd9e74a5b0d1e128'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u4e2d\u7b49\u7a0b\u5ea6\"  id='input_radio_11_62a3394f284e13a1dd9e74a5b0d1e128' aria-label='\u4e2d\u7b49\u7a0b\u5ea6' aria-invalid='false' aria-required=true> <span>\u4e2d\u7b49\u7a0b\u5ea6<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_066fde3549737c129d03ef7677a7f82f'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5f37\u70c8\"  id='input_radio_11_066fde3549737c129d03ef7677a7f82f' aria-label='\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u5f37\u70c8<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_11_179a05ec09a4227240f0c79986b7ece4'><input  type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u975e\u5e38\u5f37\u70c8\"  id='input_radio_11_179a05ec09a4227240f0c79986b7ece4' aria-label='\u975e\u5e38\u5f37\u70c8' aria-invalid='false' aria-required=true> <span>\u975e\u5e38\u5f37\u70c8<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_6_phone' id='label_ff_6_phone'>\u53ef\u4ee5\u806f\u7e6b\u7684\u96fb\u8a71<\/label><\/div><div class='ff-el-input--content'><input name=\"phone\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone\" id=\"ff_6_phone\" inputmode=\"tel\"  aria-invalid='false' aria-required=true><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u65b9\u4fbf\u63a5\u807d\u7684\u6642\u6bb5\uff08\u9810\u7d04\u8aee\u8a62\uff1a\u52d9\u5fc5\u52a0\u5165\u5b98\u65b9line\u4e26\u56de\u50b3\u53ef\u901a\u8a71\u6642\u9593\uff09<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_2b0daf5e4e6be62c9603c292d4a2b8f5'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u5e73\u65e5 \u4e0a\u5348\"  id='checkbox_3_2b0daf5e4e6be62c9603c292d4a2b8f5' aria-label='\u5e73\u65e5 \u4e0a\u5348' aria-invalid='false' aria-required=true> <span>\u5e73\u65e5 \u4e0a\u5348<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_578ac740189501beeaa3ea19c859d72a'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u5e73\u65e5 \u4e2d\u5348\"  id='checkbox_3_578ac740189501beeaa3ea19c859d72a' aria-label='\u5e73\u65e5 \u4e2d\u5348' aria-invalid='false' aria-required=true> <span>\u5e73\u65e5 \u4e2d\u5348<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='checkbox_3_08a86f9f54259018c339778b40df652a'><input  type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"\u5e73\u65e5 \u4e0b\u5348\"  id='checkbox_3_08a86f9f54259018c339778b40df652a' aria-label='\u5e73\u65e5 \u4e0b\u5348' aria-invalid='false' aria-required=true> <span>\u5e73\u65e5 \u4e0b\u5348<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u9080\u8acb\u60a8\u52a0\u5165\u6613\u601d\u8166\u5b98\u65b9LINE\uff0c\u6211\u5011\u5c07\u900f\u904e\u5b98\u65b9Line\u63d0\u4f9b\u7dda\u4e0a\u514d\u8cbb\u5c08\u5c6c\u901a\u8a71\u8aee\u8a62\u670d\u52d9\u4ee5\u53ca\u7368\u5bb6\u5927\u8166\u53ef\u5851\u6027\u5f71\u7247<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_13_940c13fd5ef15f3f1b0f90daea39f475'><input  type=\"radio\" name=\"input_radio_13\" data-name=\"input_radio_13\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u52a0\u5165\u6613\u601d\u8166\u5b98\u65b9LINE\uff0c\u4e26\u5df2\u56de\u50b3\u95dc\u9375\u5b57\u300c\u5fc3\u8166\u9858\u671b\u300d\u624d\u6709\u6210\u529f\u958b\u901a\u5594\"  id='input_radio_13_940c13fd5ef15f3f1b0f90daea39f475' aria-label='\u52a0\u5165\u6613\u601d\u8166\u5b98\u65b9LINE\uff0c\u4e26\u5df2\u56de\u50b3\u95dc\u9375\u5b57\u300c\u5fc3\u8166\u9858\u671b\u300d\u624d\u6709\u6210\u529f\u958b\u901a\u5594' aria-invalid='false' aria-required=true> <span>\u52a0\u5165\u6613\u601d\u8166\u5b98\u65b9LINE\uff0c\u4e26\u5df2\u56de\u50b3\u95dc\u9375\u5b57\u300c\u5fc3\u8166\u9858\u671b\u300d\u624d\u6709\u6210\u529f\u958b\u901a\u5594<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff_list_inline'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  >\u5f9e\u4ec0\u9ebc\u7ba1\u9053\u5f97\u77e5\u300e\u6613\u601d\u8166\u300f\uff1f<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_2ff0a455e75476e1d4faf0efad66253c'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Facebook\u793e\u7fa4\u5a92\u9ad4\"  id='input_radio_15_2ff0a455e75476e1d4faf0efad66253c' aria-label='Facebook\u793e\u7fa4\u5a92\u9ad4' aria-invalid='false' aria-required=true> <span>Facebook\u793e\u7fa4\u5a92\u9ad4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_b53c8ccc3d415b1f6c4f374c7c25f48e'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Instagram\u793e\u7fa4\u5a92\u9ad4\"  id='input_radio_15_b53c8ccc3d415b1f6c4f374c7c25f48e' aria-label='Instagram\u793e\u7fa4\u5a92\u9ad4' aria-invalid='false' aria-required=true> <span>Instagram\u793e\u7fa4\u5a92\u9ad4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_40212dc2539597d5c81ebd0519c137d1'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"YouTub\u5f71\u97f3\u5e73\u53f0\"  id='input_radio_15_40212dc2539597d5c81ebd0519c137d1' aria-label='YouTub\u5f71\u97f3\u5e73\u53f0' aria-invalid='false' aria-required=true> <span>YouTub\u5f71\u97f3\u5e73\u53f0<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_59a82d6fa1670683e31a5d9bdd854b3f'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u5a92\u9ad4\u7db2\u7ad9(\u806f\u5408\u7dda\u4e0a\u3001\u9060\u898b\u3001\u96c5\u864e\u7b49)\"  id='input_radio_15_59a82d6fa1670683e31a5d9bdd854b3f' aria-label='\u5a92\u9ad4\u7db2\u7ad9(\u806f\u5408\u7dda\u4e0a\u3001\u9060\u898b\u3001\u96c5\u864e\u7b49)' aria-invalid='false' aria-required=true> <span>\u5a92\u9ad4\u7db2\u7ad9(\u806f\u5408\u7dda\u4e0a\u3001\u9060\u898b\u3001\u96c5\u864e\u7b49)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_80372db23b63da5565adfaf239e3dbfd'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u7db2\u8def\u5ee3\u544a(Google\u3001Line\u7b49)\"  id='input_radio_15_80372db23b63da5565adfaf239e3dbfd' aria-label='\u7db2\u8def\u5ee3\u544a(Google\u3001Line\u7b49)' aria-invalid='false' aria-required=true> <span>\u7db2\u8def\u5ee3\u544a(Google\u3001Line\u7b49)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_0226da3b69226712d668f5f09a6c40e9'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u8a0e\u8ad6\u7db2\u7ad9(Dcard\u3001mobile01\u3001PTT\u7b49)\"  id='input_radio_15_0226da3b69226712d668f5f09a6c40e9' aria-label='\u8a0e\u8ad6\u7db2\u7ad9(Dcard\u3001mobile01\u3001PTT\u7b49)' aria-invalid='false' aria-required=true> <span>\u8a0e\u8ad6\u7db2\u7ad9(Dcard\u3001mobile01\u3001PTT\u7b49)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_5e3d6db3d36e64789b889bb843cb6149'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u7db2\u8def\u641c\u5c0b(\u76f8\u95dc\u5b57\u53e5\u641c\u5c0b)\"  id='input_radio_15_5e3d6db3d36e64789b889bb843cb6149' aria-label='\u7db2\u8def\u641c\u5c0b(\u76f8\u95dc\u5b57\u53e5\u641c\u5c0b)' aria-invalid='false' aria-required=true> <span>\u7db2\u8def\u641c\u5c0b(\u76f8\u95dc\u5b57\u53e5\u641c\u5c0b)<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_b47546eed8fb9525a6e903564590a813'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u89aa\u670b\u597d\u53cb\u8f49\u4ecb\"  id='input_radio_15_b47546eed8fb9525a6e903564590a813' aria-label='\u89aa\u670b\u597d\u53cb\u8f49\u4ecb' aria-invalid='false' aria-required=true> <span>\u89aa\u670b\u597d\u53cb\u8f49\u4ecb<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for='input_radio_15_253a2ffa9e375e4b6a6948c5b9ce4d28'><input  type=\"radio\" name=\"input_radio_15\" data-name=\"input_radio_15\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"\u76f8\u95dc\u5834\u57df(\u8a3a\u7642\u3001\u5fa9\u5065\u7b49)\"  id='input_radio_15_253a2ffa9e375e4b6a6948c5b9ce4d28' aria-label='\u76f8\u95dc\u5834\u57df(\u8a3a\u7642\u3001\u5fa9\u5065\u7b49)' aria-invalid='false' aria-required=true> <span>\u76f8\u95dc\u5834\u57df(\u8a3a\u7642\u3001\u5fa9\u5065\u7b49)<\/span><\/label><\/div><div class='ff-el-form-check 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