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["紹介状",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（診療情報提供書・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,"令和",null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日"]
[]
[]
[]
[]
["北播磨総合医療センター",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,"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」"]
[]
[]
[]
["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,null,"担当医師名：",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"]
[]
[]
["予約希望日",null,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,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,"-"]
[]
[]
["参考までに貴医療機関での、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,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,"-"]
[]
["次回診察日",null,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,null,null,null,null,null,null,null,null,null,null,null,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："]
[]
[]
[]
["- 検査に際してのお願い -\n医療安全ならびに職員の放射線被ばく防止の観点から、原則2時間以上一人で待機できることおよび一人でトイレに行ける方が対象となります。画像データ・検査データをご持参ください。 身長・体重は必ず記載してください。"]
[]
[]
[]
[]
[]
[]
["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,null,null,null,null,null,"受診歴",null,null,null,null,"性別",null,null,null,null,null,"患者さん予約待ち状況"]
[]
["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,"有",null,null,null,null,"男",null,null,null,null,null,"貴医療機関にて外来待機中"]
[]
[]
[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,"女",null,null,null,null,null,"貴医療機関に入院中"]
[]
[]
["旧　　姓",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※お分かりでしたらご記入お願いします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"帰宅され、貴医療機関より連絡待ち"]
[]
["生年月日",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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　（",null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,"月",null,null,null,null,null,null,null,null,"日",null,null,null,null,null,null,null,"歳"]
[]
[]
["住　　所",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,null,"連絡先",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（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）",null,null,null,null,null,null,null,null,null,null,null,null,null,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。"]
[]
[]
[]
[]
[]
["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"]
[]
[]
["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："]
[]
[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,"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"]
[]
["　　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,"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㈹"]
[]
[]
[]
["2024-04-01"]