2盒 | 3盒 | 3盒半 | 4盒 | 5盒 | 6盒 |
____________ | ____________ | ____________ | ____________ | ____________ | ____________ |
____________ | ____________ | ____________ | ____________ | ____________ | ____________ |
姓名 | 年龄 | 性别 | 联系电话 | 体重 | 身高 |
____________ | ____________ | ____________ | ____________ | ____________ | ____________ |
____________ | ____________ | ____________ | ____________ | ____________ | ____________ |
不良反应 | 依从性 | 耐受性 | 满意度 |
____________ | ____________ | ____________ | ____________ |
____________ | ____________ | ____________ | ____________ |
右半结肠 | 横结肠 | 左半结肠 | 总分 |
____________ | ____________ | ____________ | ____________ |
____________ | ____________ | ____________ | ____________ |