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[]
[null,null,null,null,null,null,null,null,null,null,"検査日：",null,null,null,"令和",null,null,null,"年",null,"月",null,"日","（",null,"）",null,null,"時",null,null,"分"]
[null,"冠動脈ＣＴ　患者情報"]
[null,"紹介元医療機関名","(",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,"患者氏　名",null,null,null,null,null,null,null,null,null,null,null,null,null,"様"]
[null,"年　齢",null,null,null,null,"歳"]
[null,"性　別","　　　　　　　　　　　　　　　　　　　　　"]
[null,"身　長",null,null,null,null,null,null,null,"cm"]
[null,"体　重",null,null,null,null,null,null,null,"kg"]
[null,"検査目的","　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,")"]
[null,"リスクファクター",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,")","　"]
[null,"ステントの有無",null,null,null,null,null,null,null,"（種類が判ればご記入ください…",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,"ペースメーカーの有無",null,null,null,null,null,null,null,"（種類が判ればご記入ください…",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,"不整脈の有無",null,null,null,null,null,null,null,"…",null,null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,")"]
[null,"βブロッカーの使用"]
[null,"喘息の有無",null,null,null,null,null,null,null,"（有りの場合は外来での検査は行いません）"]
[null,"アレルギー歴",null,null,null,null,null,null,null,"（有りの場合は造影剤副作用のリスクが増えます）"]
[null,"造影歴の有無",null,null,null,null,null,null,null,"［副作用",null,null,null,null,null,null,null,"］","（副作用ありの場合は外来検査は行いません）"]
[null,"ビグアナイド系\n糖尿病薬の服用"]
[]
[null,"eGFR",null,null,null,null,"mg/dl　",null,null,"(",null,"月",null,"日",")","３ヶ月以内のデータ・・・45未満は検査は行いません。"]
[null,"血圧(受診時）",null,null,null,"/",null,null,null,"mmHg"]
[null,"心拍数（受診時）","                      ",null,null,null,null,null,null," bpm"]
[null,"特記事項"]
[]
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[]
[]
[]
[]
[]
[]
[null,"※　冠動脈CTを依頼いただく際は、この患者情報も一緒にFAXしてください。"]
[]
[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）TEL0794-88-8800"]
[null,"地域医療連携室　FAX番号（0794）62－9911"]
[null,"予約受付時間：　平　日　9:00～18:30     土曜日　9:00～11:30"]
[]
[]
[null,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２年８月更新"]