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["紹介状 [診療情報提供書(放射線治療依頼用)]",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,null,null,null,"令和",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"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,null,null,null,null,null,null,null,null,null,"紹介元医療機関名及び所在地：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※改行は　「Altキー　＋　Enterキー」"]
["北播磨総合医療センター"]
[]
[]
[]
[]
["放射線治療科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当医　先生"]
[]
[]
[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,"担当医師名：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"印"]
[]
[]
["予約希望日",null,null,null,null,null,null,"第１希望",null,null,null,null,null,null,null,null,"月",null,null,null,null,"日",null,"(",null,null,null,")",null,null,null,"時頃",null,null,null,"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,"-"]
[]
[]
["毎週金曜日午前のみ",null,null,null,null,null,null,"第２希望",null,null,null,null,null,null,null,null,"月",null,null,null,null,"日",null,"(",null,null,null,")",null,null,null,"時頃",null,null,null,"ＦＡＸ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,"-"]
[]
[]
[]
["フ リ ガ ナ",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,"旧姓",null,null,null,null,null,null,null,null,null,"性別",null,null,null,null,null,null,"生　年　月　日"]
[]
["患者氏名",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,"受診歴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 明治",null,null,null,null,null," 大正",null,null,null,null,null," 昭和",null,null,null,null,null," 平成",null,null,null,null,null,"　令和"]
[]
[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,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,null,null,null,null,"歳"]
[]
["住所",null,null,null,null,"〒",null,null,null,null,null,null,"-"]
[]
[]
[]
[]
[]
["自宅",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,"連絡先",null,null,null,null,null,"(",null,null,null,null,null,null,")",null,null,null,null,null,null,"-"]
[]
["主保険",null,null,"保険者番号",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,null,null,"併用保険",null,null,"負担者番号"]
[]
[]
[]
[null,null,null,"記号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受給者番号"]
[]
[]
[]
["来院方法",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,"その他特記事項",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,")"]
[]
[]
["患者さんの都合により当医療センターと直接予約日を変更することについて",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,null,null,null,null,null,null,null,"不承諾並びにどちらにもチェックがない場合は従来どおり紹介元を通しての変更をお願いします。"]
[]
[]
[]
[]
["放射線治療に際し、該当する箇所にチェックをお願いします。"]
[]
[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,"※北播磨総合医療センターでの入院放射線治療をご希望の場合は、\n　　　　　　がん種・原発部位・病状に応じて各診療科にご紹介お願いします。"]
[]
[]
[]
["臨床診断",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,"本人への告知"]
[]
[]
[]
["病理組織\n診断",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,"未告知の場合の患者さんへの説明内容"]
[]
[]
[]
["放射線治療予定部位"]
[]
[]
[]
["既往治療歴　",null,null,null,null,null,null,null,"原疾患手術・化学療法、放射線治療",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,"※内容記載、もしくは資料添付お願いします。"]
[]
[]
[]
[]
[]
["合併症",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※内容記載、もしくは資料添付お願いします。"]
[]
[]
[]
[]
[]
["臨床経過とご依頼内容",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,null,null,null,null,null,null,null,"※改行は　「Altキー　＋　Enterキー」"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["患者に関する留意事項、薬剤アレルギー、嗜好"]
[]
[]
[]
[]
[]
[]
["添付資料",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,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,")"]
[]
[]
["北播磨総合医療センター 〒675-1392 兵庫県小野市市場町926-250 代表TEL 0794-88-8800"]
[]
["地域医療連携室   FAX番号（0794)62-9911"]

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