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["连州市         镇（乡）农村留守老年人巡访登记表"]
["巡访单位（盖章）："]
["姓名",null,"性别",null,"巡访时间"]
["类型","重点巡访",null,null,"巡访\n责任人"]
[null,"普遍巡访"]
["住址"]
["巡  访  内  容"]
["健康状况",null,"表达能力","□优","□良","□中","□差"]
[null,null,"行动能力","□优","□良","□中","□差"]
[null,null,"疾病状况","□优","□良","□中","□差"]
["精神状态",null,"情绪状态","□优","□良","□中","□差"]
[null,null,"思维状态","□优","□良","□中","□差"]
[null,null,"压力状态","□优","□良","□中","□差"]
["安全情况",null,"燃气安全","□安全",null,"□不安全"]
[null,null,"取暖安全","□安全",null,"□不安全"]
[null,null,"用电安全","□安全",null,"□不安全"]
["卫生状况",null,"个人卫生","□清洁",null,"□不清洁"]
[null,null,"家庭卫生","□清洁",null,"□不清洁"]
[null,null,"周边卫生","□清洁",null,"□不清洁"]
["居住环境",null,"室内环境","□安全",null,"□不安全"]
[null,null,"室外环境","□安全",null,"□不安全"]
[null,null,"邻里关系","□安全",null,"□不安全"]
["关爱服务",null,"生活照料","□有人照料",null,"□无人照料"]
[null,null,"精神慰藉","□有需求",null,"□无需求"]
[null,null,"权益维护","□有需求",null,"□无需求"]
[null,null,"安全监护","□有需求",null,"□无需求"]
["其他情况说明"]
["巡访人员签名："]

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["连州市             镇（乡）           年农村留守老年人巡访台账"]
[]
["序号","姓名","性\n别","巡访\n时间","巡访\n类型","住址","巡访内容",{"$nulls":5},"巡访\n责任人","备注"]
[{"$nulls":6},"健康状况","精神状态","安全情况","卫生状况","居住环境","关爱服务需求"]
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["注：巡访内容在对应的单位格内打“√”，巡访具体内容在《连州市农村留守老年人巡访登记表》查阅。"]