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["診療情報提供書　（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,null,null,null,null,null,"男"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"作成日",null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,null,"女"]
[]
["公立藤岡総合病院"]
[null,null,null,null,"科",null,null,null,null,null,"先生",null,null,null,null,"紹介元医療機関",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"明治"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"昭和"]
["フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,"性別",null,"生年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"平成"]
["患者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,null,"令和"]
["住　所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年齢",null,null,null,null,"歳"]
["電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"携帯番号"]
["身　長",null,null,null,null,null,"㎝","体　重",null,null,null,null,null,"kg","※造影剤使用量や、MRIでの出力の目安として用います。"]
["検査日",null,null,null,null,null,"年",null,null,"月",null,null,null,"日",null,null,"午前",null,null,"午後",null,null,null,"時",null,null,"分"]
[]
["依頼検査",null,null,null,null,"ＣＴ",null,null,null,"ＭＲＩ",null,null,null,"ＲＩ",null,null,null,null,null,null,"PET-CT",null,null,null,"骨密度"]
["検査部位",null,null,null,null,"脳",null,null,null,"脳",null,null,null,"骨"]
[null,null,null,null,null,"頭頸部",null,null,null,"頭頸部",null,null,null,"脳血流(ECD)"]
[null,null,null,null,null,"頸部",null,null,null,"頸部",null,null,null,"DAT"]
[null,null,null,null,null,"胸部",null,null,null,"胸部",null,null,null,"心臓交感神経(MIBG)"]
[null,null,null,null,null,"腹部",null,null,null,"腹部",null,null,null,"肺血流(MAA)"]
[null,null,null,null,null,"骨盤部",null,null,null,"骨盤部",null,null,null,"レノグラム（MAG3)"]
[null,null,null,null,null,"上肢",null,null,null,"上肢",null,null,null,"その他"]
[null,null,null,null,null,"下肢",null,null,null,"下肢"]
[null,null,null,null,null,"頸椎",null,null,null,"頸椎"]
[null,null,null,null,null,"胸椎",null,null,null,"胸椎"]
[null,null,null,null,null,"腰椎",null,null,null,"腰椎"]
["造影剤使用",null,null,null,null,"無",null,null,"有"]
["感染症有無",null,null,null,null,"無",null,null,"有",null,null,"HBV",null,null,"HCV",null,null,"HIV",null,null,"ワ氏"]
["臨床診断・依頼目的・撮影指示（具体的に）"]
[]
[]
[]
[]
["検査の前処置"]
[null,"ＣＴ",null,"造影剤を使用する場合には、直前食を食べないでください。飲水（水かお茶）は推奨されます。"]
[null,"ＭＲＩ",null,"腹部・骨盤内臓器を撮影する時のみ、造影剤の有無に関わらず直前食は控えてください。その他は、造影であっても食事制限はありません。飲水（水かお茶）は可能です。"]
[null,"ＲＩ",null,"骨シンチは午後検査前の排尿のみです。午前の注射前は特にありません。"]
["【重要】　ＣＴ造影・ＭＲＩ・PET-CT検査においては、必ず当院指定の同意書を作成し、\n　　　　　　この情報提供書（検査依頼書）と一緒にFAXしてください。"]
[]
[null,"送信先 ： 公立藤岡総合病院 患者支援センター"]
[null,"電話番号 ：　０２７４-２２-６０３９　（直通）",null,null,null,null,null,null,null,null,null,null,null,null,"　FAX番号 ：　０２７４-２４-７００２　（直通）"]