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["紹 介 状",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（ＰＥＴ－ＣＴ検査依頼書）",null,null,null,null,null,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"]
[]
[]
[]
["(診療情報提供書)"]
[null,null,null,null,null,null,null,null,null,null,null,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"]
[]
[]
["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,null,"科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"印"]
[]
["予　約\n希望日",null,null,null,null,null,null,"令和",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,null,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,null,"-"]
[]
[]
["次回診察日",null,null,null,null,null,null,null,null,null,null,"\n年",null,null,null,null,null,null,null,null,null,null,null,"参考までに紹介元医療\n機関での、次回診察日\nをお聞かせください",null,null,null,null,null,null,null,null,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,null,"-"]
[]
[null,null," （",null,"令和",null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",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,"-"]
[]
[]
[]
["自宅電話",null,null,null,null,null,null,null,"(",null,null,null,null,null,null,")",null,null,null,null,null,null,"-",null,null,null,null,null,null,null,null,null,null,null,null,"携帯電話",null,null,null,null,null,null,null,"(",null,null,null,null,null,null,")",null,null,null,null,null,null,"-"]
[]
["前回検査",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,")","所見:"]
[]
[]
[]
["保険適用　条件",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（注）疑い病変は保険適用外です。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"他の検査、画像診断により病期診断、転移・再発の診断が確定できない患者に用いる。"]
[]
[]
["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,null,null,null,null,null,null,null,null,null,null,null,"（　　　　　　　　　）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（注）心サルコイドーシス疑いは保険適用外です。\n心サルコイドーシスにおける炎症部位の診断目的で依頼をお願いします。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"難治性部分てんかんで外科切除が必要とされる患者に用いる。\n（注）手術が前提にない場合は保険適用外です。"]
[]
[]
["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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（　　　　　 　　）"]
[]
[]
["自由診療",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(注)上記の病名および検査目的に該当しない場合は、自由診療となります（約11万円の自己負担）。\n     平成22年度の改正により、「肺がん疑い」、「大腸がん疑い」は保険適用外です。\n"]
[]
[]
[null,null,null,null,null,null,null,null,null,"病名",null,null,null,"：","（　　　　　　　　　　　　　　）"]
[]
[]
[]
["臨床経過等（①現病歴　②現症　③検査所見　④治療経過　⑤現在の処方　⑥その他）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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\n「Altキー　＋　Enterキー」"]
[]
[]
[]
[]
[]
[]
[]
["当該疾患の治療歴",null,null,null,null,null,null,"手術療法",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日",null,"化学療法",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"最終日",null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[null,null,null,null,null,null,null,"術式",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"放射線療法",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"最終日",null,null,null,null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[]
["患　　者　　情　　報"]
["身体情報",null,null,null,null,null,null,null,"身長",null,null,null,null,null,null,null,null,null,"cm",null,null,"体重",null,null,null,null,null,null,null,null,null,"kg",null,null,null,"糖尿病",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(","空腹時血糖",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※糖尿病薬剤を検査当日に服用（投与）するのは避けてください。\n※検査当日の血糖値が200mg/dl以上の場合は検査を中止する場合があります。"]
[]
[]
["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,")"]
[]
[]
["ＰＥＴ検査歴",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,"月",null,null,null,"日",null,null,null,"所見："]
[]
["告知の有無",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※必ずご記入ください。"]
[]
["難聴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"腎機能障害",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"酸素吸入"]
[]
["認知症",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",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"インスリン使用"]
[]
["感染症"]
[]
["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,")"]
[]
[]
["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。"]
[]
[]
[]
[]
["　　結果（所見）返送方法",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"結果が出来次第、医療機関様へ配送します。（約1週間程度要します。）"]
[]
["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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