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["紹介状",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（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,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"]
[]
[]
[]
["(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,"印"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,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,"-"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"-"]
["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,"申込担当者："]
[]
[]
[]
["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,"患者さん予約待ち状況"]
[]
["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,"有",null,null,null,null,null,"男",null,null,null,null,"当院外来にて待機中"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"女",null,null,null,null,"当院入院中"]
[]
["生年月日",null,null,null,null,null,null,null,null,null,"明治",null,null,null,null,null,null,"大正",null,null,null,null,null,null,"昭和",null,null,null,null,null,null,"平成",null,null,null,null,null,null,"令和",null,null,null,null,null,"帰宅の後、貴医療機関より連絡待ち"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,null,null,"月",null,null,null,null,null,null,null,"日",null,null,null,null,null,null,null,"歳",null,null,null,null,"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,"）"]
[]
["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,"独歩",null,null,null,null,null,null,"車いす",null,null,null,null,null,null,null,"ストレッチャー",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,")"]
[]
[]
["紹介目的",null,null,null,null,null,null,null,"　検査（ＣＴ）"]
[]
[]
["目的臓器\n(目的部位)",null,null,null,null,null,null,null,null,null,null,"頭部",null,null,null,null,null,null,null,"胸部",null,null,null,null,null,null,null,"上腹部",null,null,null,null,"(",null,null,null,"肝",null,null,null,null,null,"胆",null,null,null,null,null,"膵",null,null,")",null,null,null,"全腹部",null,null,null,null,null,null,null,"胸腹部"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"冠動脈",null,null,null,null,null,null,null,"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,"造影",null,null,null,null,null,null,"要",null,null,"クレアチニン",null,null,null,null,null,null,null,null,null,null,null,"eGFR",null,null,null,null,null,null,null,null,null,"※3か月以内のクレアチニン値およびeGFR値を記入してください。\n※腎機能が悪い場合、eGFR<45は、原則単純撮影でお願いします。\n※eGFR<45の場合でも、造影が必要な場合は、CT室までご連絡ください。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"不要",null,null,"〔検査日〕　　　　　　年　　　　月　　　　日"]
[]
[]
["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,"承諾する",null,null,null,null,null,null,null,null,"不承諾",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。"]
[]
[]
["（直接予約日変更時も下記予約受付時間での対応となります）"]
[]
["肝障害",null,null,null,null,null,null,null,null,null,null,"無",null,null,null,"有",null,null,"感染症",null,null,null,null,null,null,"HBs",null,null,null,null,null,null,null,null,null,"＋",null,null,null,null,null,"－",null,null,null,null,null,"未検査"]
[]
[]
["腎障害",null,null,null,null,null,null,null,null,null,null,"無",null,null,null,"有",null,null,null,null,null,null,null,null,null,"HCV",null,null,null,null,null,null,null,null,null,"＋",null,null,null,null,null,"－",null,null,null,null,null,"未検査"]
[]
[]
["アレルギー歴",null,null,null,null,null,null,null,null,null,null,"無",null,null,null,"有",null,null,null,null,null,null,null,null,null,"Wa氏",null,null,null,null,null,null,null,null,null,"＋",null,null,null,null,null,"－",null,null,null,null,null,"未検査"]
[]
[]
["喘息",null,null,null,null,null,null,null,null,null,null,"無",null,null,null,"有",null,null,null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,null,null,"＋",null,null,null,null,null,"－",null,null,null,null,null,"未検査",null,null,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,"初診",null,null,null,null,null,"再診",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:"]
[]
[]
["診断名",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,null,null,null,null,null,null,null,"主訴"]
[]
[]
["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,"※改行は　「Altキー ＋ Enterキー」"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["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,null,null,null,"すべて返送",null,null,null,null,null,null,null,null,null,"所見のみFAX、その他郵送",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"その他（　　　　　　　　　　　　　　）"]
[]
[]
["ビグアナイド系糖尿病薬の服用",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,"服薬なし",null,null,null,null,null,null,null,null,null,"服薬有り（休薬必要なし）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"服薬有り（前後５日間休薬）"]
[]
[]
[]
["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,")"]
[]
[]
[]
["※ FAX予約受付時間（月～金　9:00～18:30　土　9:00～11:30　（祝祭日・年末年始は除く））　（FAX受信は24時間可能です）"]
[]
["北播磨総合医療センター地域医療連携室　  FAX：0794-62-9911　TEL：0794-88-8800㈹"]