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["紹介状 [診療情報提供書(動脈硬化疾患外来依頼用)]",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,"令和",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,null,null,null,null,null,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"]
[]
[]
[]
[]
["循環器内科　動脈硬化疾患外来担当医先生"]
[]
[]
[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,"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,"(","水",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,"-"]
[]
[]
["第2・4水曜\n午後のみ",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,"(","水",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,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,")"]
[]
[]
["紹介目的"]
[]
[]
["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。"]
[]
[]
[]
[]
["既往歴"]
[]
[]
[]
[]
[]
["動脈硬化\nリスクファクター"]
[]
[]
[]
["患者情報",null,null,null,null,null,null,null,null,null,null,null,null," 身　長：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"cm",null,null,null,"体重：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"kg"]
[]
[]
[]
["貴院検査結果",null,null,null,null,null,null,null,null,null,null,null,null," 血糖値：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"mg/dl",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"HbA1c",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"%"]
[]
[]
[]
[]
["循環器疾患\n合併の可能性",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"“あり”の場合その理由"]
[]
[]
[]
[]
[]
[]
["心不全症状\nについて",null,null,null,null,null,null,null,null,null,null,null,null,"労作時息切れ症状"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"下腿浮腫"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"その他の症状"]
[]
[]
["投薬内容\n（お薬手帳持参\nのみでも可）"]
[]
[]
[]
[]
[]
["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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