{"text_format":"1","workbook":"xlsx","n_sheets":1,"sheets":["PET-CT"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":1,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"PET-CT","index":0,"n_rows":123,"n_cols":72,"rows_kept":123,"cut":false,"hidden":false,"merged":[[32,36,33,37],[32,38,33,41],[32,42,33,43],[32,44,33,71],[34,8,35,14],[34,15,35,17],[34,18,35,22],[34,23,35,25],[34,27,35,30],[34,31,35,33],[34,34,35,38],[34,39,35,41],[34,42,35,43],[34,44,35,48],[34,49,35,50],[34,51,35,69],[34,70,35,71],[32,0,35,7],[32,8,33,9],[32,10,33,14],[32,15,33,16],[32,17,33,21],[32,22,33,23],[32,24,33,28],[32,29,33,30],[32,31,33,35],[26,0,27,7],[26,8,27,25],[26,26,27,29],[26,30,27,35],[26,36,27,41],[26,42,27,71],[28,0,31,7],[28,8,31,25],[28,26,31,29],[28,30,29,32],[28,33,29,35],[28,36,29,38],[28,39,29,41],[28,42,29,43],[28,44,29,71],[30,30,31,32],[30,33,31,35],[30,36,31,38],[30,39,31,41],[30,42,31,43],[30,44,31,71],[122,0,124,71],[120,0,121,71],[108,24,109,35],[108,36,109,47],[108,48,109,59],[108,60,109,71],[110,0,111,7],[110,8,111,12],[110,13,111,18],[110,19,111,24],[110,25,111,35],[110,36,111,44],[110,45,111,54],[110,55,111,62],[110,63,111,63],[110,64,111,70],[110,71,111,71],[108,0,109,0],[108,1,109,10],[108,11,109,11],[112,0,116,32],[112,51,116,71],[117,0,118,22],[117,23,118,71],[102,17,103,19],[106,48,107,48],[106,49,107,58],[102,0,103,7],[102,20,103,71],[104,11,105,11],[104,1,105,10],[104,0,105,0],[104,24,105,24],[104,25,105,34],[104,35,105,35],[106,0,107,0],[106,1,107,10],[106,11,107,11],[97,0,99,7],[97,34,99,43],[97,44,99,44],[97,45,99,70],[106,24,107,24],[106,25,107,34],[106,35,107,35],[106,60,107,62],[106,63,107,65],[106,66,107,68],[106,69,107,71],[106,59,107,59],[104,59,105,59],[104,12,105,14],[104,15,105,17],[104,18,105,20],[104,21,105,23],[106,12,107,14],[106,15,107,17],[106,18,107,20],[106,21,107,23],[102,8,103,10],[102,11,103,13],[102,14,103,16],[89,0,89,71],[92,47,93,51],[92,52,93,52],[92,53,93,60],[97,71,99,71],[100,0,101,7],[100,20,101,23],[100,24,101,25],[100,26,101,28],[100,29,101,30],[100,31,101,33],[100,34,101,35],[100,37,101,41],[100,42,101,71],[100,8,101,10],[100,11,101,13],[100,14,101,16],[100,17,101,19],[97,8,99,10],[97,11,99,14],[97,15,99,17],[97,18,99,22],[97,23,99,25],[97,26,99,33],[63,0,65,7],[66,0,71,7],[85,64,86,65],[85,66,86,67],[85,68,86,69],[85,70,86,71],[87,7,88,11],[87,53,88,57],[85,14,86,15],[85,16,86,17],[85,18,86,19],[85,22,86,26],[85,27,86,28],[85,29,86,30],[85,31,86,32],[85,33,86,34],[85,35,86,36],[85,37,86,44],[87,12,88,36],[87,37,88,44],[87,58,88,61],[87,62,88,63],[87,64,88,65],[87,66,88,67],[66,8,68,15],[66,16,68,71],[69,9,71,12],[69,13,71,13],[69,14,71,36],[72,0,72,71],[85,53,86,57],[85,58,86,61],[85,62,86,63],[75,0,84,71],[85,0,88,6],[85,7,86,13],[85,20,86,21],[85,47,86,48],[87,47,88,48],[87,51,88,52],[85,51,86,52],[87,49,88,50],[85,49,86,50],[85,45,86,46],[87,45,88,46],[87,68,88,69],[87,70,88,71],[42,42,44,45],[42,46,44,71],[45,0,45,71],[46,0,50,7],[46,35,48,71],[49,11,50,71],[51,0,62,7],[57,24,59,71],[60,24,62,71],[42,0,44,7],[42,20,44,20],[42,21,44,25],[42,26,44,28],[42,29,44,31],[42,32,44,34],[42,35,44,37],[42,17,44,19],[42,11,44,13],[42,8,44,10],[42,14,44,16],[42,38,44,40],[42,41,44,41],[36,8,37,11],[36,12,37,13],[36,14,37,18],[36,19,37,71],[40,24,41,29],[40,30,41,34],[40,35,41,42],[40,43,41,43],[40,44,41,49],[40,50,41,50],[40,51,41,56],[40,57,41,58],[40,59,41,64],[40,22,41,23],[14,31,17,32],[14,33,17,33],[16,35,18,45],[16,46,18,47],[16,48,18,53],[16,54,18,55],[16,56,18,61],[16,62,18,63],[16,64,18,71],[13,35,15,45],[13,46,15,53],[13,54,15,55],[13,56,15,68],[13,69,15,71],[14,0,17,5],[14,7,17,11],[14,12,17,14],[14,15,17,17],[14,18,17,20],[14,21,17,23],[14,24,17,26],[14,27,17,29],[14,30,17,30],[19,48,21,53],[19,54,21,55],[22,35,24,45],[40,65,41,71],[22,46,24,71],[21,18,24,20],[21,21,24,23],[21,24,24,26],[21,27,24,29],[21,30,24,30],[21,31,24,32],[21,33,24,33],[19,35,21,45],[19,46,21,47],[19,56,21,61],[19,62,21,63],[19,64,21,71],[19,0,20,34],[21,0,24,5],[21,7,24,11],[21,12,24,14],[21,15,24,17],[36,0,37,4],[36,5,37,7],[0,0,3,14],[0,15,3,44],[4,0,5,14],[7,35,12,71],[10,0,12,33],[6,0,9,33],[0,49,3,53],[0,54,3,56],[0,57,3,59],[0,60,3,62],[0,63,3,65],[0,66,3,68],[0,69,3,71],[4,35,4,71],[5,35,6,54],[5,55,6,71],[112,45,116,50],[112,42,116,44],[112,36,116,41],[112,33,116,35],[104,36,105,38],[104,39,105,41],[104,42,105,44],[104,45,105,47],[106,36,107,38],[106,39,107,41],[104,48,105,48],[104,49,105,58],[106,42,107,44],[106,45,107,47],[108,12,109,14],[108,15,109,17],[108,18,109,20],[108,21,109,23],[73,0,74,54],[38,0,39,71],[40,0,41,7],[40,8,41,8],[40,9,41,14],[40,15,41,15],[40,16,41,21],[54,52,56,53],[54,54,56,69],[54,70,56,71],[63,54,65,55],[63,70,65,71],[63,56,65,69],[104,60,105,62],[104,63,105,65],[104,66,105,68],[104,69,105,71],[73,55,74,71],[92,61,93,65],[92,66,93,69],[92,70,93,70],[94,37,96,71],[90,0,91,71],[92,0,96,7],[92,8,96,12],[92,13,96,19],[92,20,96,22],[92,23,96,27],[92,28,96,33],[92,34,96,36],[92,37,93,41],[92,42,93,46]]}
["紹介状",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,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,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,"-"]
[]
[]
["参考までに紹介元医療機関での、次回診察日をご記入ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"-"]
[]
["次　回\n診察日",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,"初診",null,null,null,null,null,"再診",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\n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,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,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。"]
[]
[]
[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,"※改行は「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,"無",null,null,null,"有",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,"無",null,null,null,"有",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,null,null,"放射線療法",null,null,null,null,null,null,null,null,null,"無",null,null,null,"有",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,null,null,"cm",null,null,"体重",null,null,null,null,null,null,null,null,null,null,"kg",null,null,"糖尿病",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,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,"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,")"]
[]
[]
["ＰＥＴ検査歴",null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有",null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日",null,null,"所見："]
[]
["告知の有無",null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有",null,null,"※必ずご記入ください。"]
[]
[null,"難聴",null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有",null,null,null,"腎機能障害",null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有",null,null,null,"酸素吸入",null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有"]
[]
[null,"認知症",null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有",null,null,null,"ペースメーカー",null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有",null,null,null,"インスリン使用",null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有"]
[]
[null,"感染症",null,null,null,null,null,null,null,null,null,null,null,null,null,"無",null,null,null,null,null,"有"]
[]
["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,"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。"]
[]
[]
[]
[]
["　　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。）"]
[]
[]
["※ 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㈹"]