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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査日：",null,null,null,null,null,null,null,"令和",null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日",null,"（",null,null,"）",null,null,null,"時",null,null,null,null,"分"]
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["冠動脈ＣＴ　患者情報"]
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[null,"紹介元医療機関名",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,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,null,null,null,null,null,null,null,null,null,null,null,null,")"]
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[null,"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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様"]
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[null,"年　齢",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"歳"]
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[null,"性　別",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　　　　　　　　　　　　　　　　　"]
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[null,"身長",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"cm"]
[]
[]
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[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,")"]
[]
[]
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[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,")"]
[]
[]
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[null,"ステントの有無",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,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
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[null,"ペースメーカーの有無",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,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
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[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,")"]
[]
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[null,"βブロッカーの使用"]
[]
[]
[]
[null,"喘息の有無",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,null,"（有りの場合は外来での検査は行いません）"]
[]
[]
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[null,"アレルギー歴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"［副作用",null,null,null,null,null,null,null,null,null,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）"]
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[null,"ビグアナイド系\n糖尿病薬の服用"]
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[]
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[null,"eGFR",null,null,null,null,null,null,null,null,null,null,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,"月",null,null,null,"日",null,"）","３ヶ月以内のデータ … 45未満は検査は行いません。"]
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[null,"血圧(受診時）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"/",null,null,null,null,null,null,null,null,null,null,null,"mmHg"]
[]
[]
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[null,"心拍数（受診時）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," bpm"]
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[]
[]
[null,"特記事項"]
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["※　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。"]
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["※ 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）"]
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["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㈹"]