{"text_format":"1","workbook":"xlsx","n_sheets":1,"sheets":["紹介状（認知症ｾﾝﾀｰ）"],"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":"紹介状（認知症ｾﾝﾀｰ）","index":0,"n_rows":119,"n_cols":71,"rows_kept":119,"cut":false,"hidden":false,"merged":[[61,53,65,71],[20,21,24,24],[20,25,24,26],[20,27,24,28],[61,0,65,34],[61,35,65,37],[61,38,65,43],[61,44,65,46],[61,47,65,52],[51,50,53,69],[51,70,53,71],[51,8,53,39],[51,40,53,43],[51,44,53,49],[46,42,47,42],[46,43,47,48],[20,9,24,12],[20,13,24,14],[57,26,58,39],[57,41,58,44],[36,42,37,71],[36,0,40,5],[36,6,37,7],[59,4,60,7],[54,4,56,71],[57,4,58,7],[57,8,58,20],[57,22,58,25],[57,45,58,68],[59,8,60,39],[43,0,45,71],[46,0,47,5],[46,6,47,6],[46,7,47,12],[46,13,47,13],[46,14,47,19],[46,20,47,21],[46,22,47,27],[46,28,47,35],[46,36,47,41],[46,64,47,71],[48,4,50,7],[48,8,50,39],[48,40,50,43],[48,44,50,71],[51,4,53,7],[48,0,60,3],[46,49,47,49],[41,0,42,5],[41,6,42,8],[41,9,42,19],[41,20,42,71],[38,24,40,29],[38,30,40,32],[38,33,40,37],[38,38,40,40],[38,42,39,43],[38,44,39,49],[46,50,47,55],[46,56,47,57],[46,58,47,63],[38,52,39,58],[38,59,39,60],[38,61,39,71],[34,0,35,5],[34,6,35,18],[34,19,35,40],[34,42,35,43],[34,44,35,49],[34,50,35,69],[34,70,35,71],[36,8,37,12],[36,13,37,14],[36,15,37,19],[36,20,37,21],[38,6,40,11],[38,12,40,14],[38,15,40,20],[38,21,40,23],[38,50,39,51],[36,22,37,26],[36,27,37,28],[36,29,37,33],[36,34,37,35],[36,36,37,40],[26,0,27,5],[26,6,27,30],[26,31,27,35],[26,36,27,40],[26,42,27,71],[28,0,33,5],[28,6,33,30],[28,31,30,32],[28,33,30,35],[28,36,30,37],[32,44,33,71],[28,38,30,40],[28,42,29,43],[28,44,29,71],[30,42,31,43],[30,44,31,71],[31,31,33,32],[31,33,33,35],[31,36,33,37],[31,38,33,40],[32,42,33,43],[114,0,116,71],[118,0,119,71],[106,24,107,33],[109,0,109,71],[110,0,111,71],[112,0,113,71],[66,0,67,50],[66,56,67,70],[69,1,104,70],[106,2,107,9],[106,10,107,14],[106,15,107,23],[106,34,107,40],[106,41,107,41],[106,70,107,70],[106,42,107,69],[68,0,68,71],[22,36,24,45],[22,46,24,71],[19,36,21,45],[19,46,21,47],[19,48,21,53],[19,54,21,55],[20,33,24,34],[16,64,18,71],[16,36,18,45],[16,46,18,47],[16,48,18,53],[16,54,18,55],[16,56,18,61],[16,62,18,63],[17,0,18,34],[20,29,24,32],[19,56,21,61],[19,62,21,63],[19,64,21,71],[20,0,24,4],[20,5,24,8],[20,15,24,18],[20,19,24,20],[13,46,15,53],[13,54,15,55],[13,56,15,68],[13,69,15,71],[9,0,12,34],[14,0,16,2],[0,62,3,64],[0,65,3,67],[0,68,3,70],[5,0,8,34],[5,36,6,55],[5,56,6,71],[7,36,12,71],[0,0,3,14],[0,15,3,44],[0,46,3,52],[0,53,3,55],[0,56,3,58],[0,59,3,61],[14,15,16,17],[14,3,16,13],[14,18,16,34],[13,36,15,45]]}
["紹介状",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（診療情報提供書・診察予約用）",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,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」"]
[]
[]
[]
["認知症診療センター"]
[]
[]
[]
[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,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"]
[null,null,null,"もの忘れ外来",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"抗Aβ抗体治療外来"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,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,"-"]
["※上記希望外来に☑を入れてください。"]
[]
[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,"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,"-"]
["受診\n希望日",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,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,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,null,null,null,null,null,null,null,null,null,null,null,"貴医療機関に入院中"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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"]
[]
["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,"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,"）"]
[]
["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,"患者さん来院方法"]
[]
[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",null,null,null,null,null,"独歩",null,null,null,null,null,null,null,"車イス",null,null,null,null,null,null,null,null,"ストレッチャー"]
[]
[]
["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,"-"]
[]
["紹\n介\n目\n的",null,null,null,null,null,null,null,"もの忘れの原因精査",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"運転免許証更新に係る認知機能検査"]
[]
[]
[null,null,null,null,null,null,null,null,"抗Aβ抗体薬（レカネマブ・ドナネマブ）による治療",null,null,null,null,null,null,null,null,null,null,null,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,"抗Aβ抗体治療外来を希望される方は、以下のすべての項目に該当することをご確認下さい。\n1つでも該当しない場合は、もの忘れ外来の受診となります。"]
[]
[]
[null,null,null,null,null,null,null,null,"40歳～90歳である",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"もの忘れが軽度である",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　問診上、脳出血および脳挫傷の既往がない"]
[]
[null,null,null,null,null,null,null,null,"点滴目的に１ヶ月に1回以上、当院への通院が可能"]
[]
["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。"]
[]
[]
[]
[]
["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,"※改行は　「Alt　＋　Enter 」"]
[]
["※症状出現時期を記載ください　□2週間以内　□2週間以上経過"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,"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,"）"]
[]
[]
[]
["※ 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）"]
[]
["受付時間外のお申し込みは、翌業務日以降のお返事となります。※診療科、医師によっては当日のお返事ができない場合があります。"]
[]
["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㈹"]
[]
[]
[]
["2025-08-01"]