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["この欄は貴院IDのご記入・エンボス印字等にご利用ください。",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜１枚目＞"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ゆうあいクリニック宛"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療情報提供書（画像診断依頼書）"]
[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,null,null,null,"ゆうあいクリニック　吉田　啓介　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,null,null,null,null,null,"以下の患者様の画像診断をお願い申し上げます。"]
[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,null,null,null,"予約日時：",null,null,null,null,null,null,null,null,null,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,"時",null,null,null,null,null,"分"]
[]
["貴医療機関名",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,"診療科\n\n",null,null,null,null,null,null,null,null,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（フルネーム）"]
[]
["TEL:",null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,"）"]
["▽依頼内容",null,null,null,null,null,null,null,null,null,"※PET検査またはPET/CT検査にMRI検査を追加した場合、「総合画像診断」という名称を使用します。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※保険診療の算定要件では原則６か月以上の間隔をとることとされています。\n患者様の病状等によりどうしても短期間での検査が必要な場合は、その理由を詳しくご記載ください。\n※PET/CT装置の特性上、吸収補正は低線量CTで減弱補正を行います。"]
[]
[]
["（頭頂部から大腿基部まで）"]
[]
[]
[]
[null,null,null,null,null,"糖 尿 病",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,"BS",null,null,null,null,null,null,null,null,null,null,"mg/dl）",null,null,null,null,null,null,"※糖尿病薬剤は検査当日の使用を避けてください。\n※空腹時血糖200mg/dlを超える場合はご相談ください。"]
[]
[]
[]
[]
[]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,"目的臓器：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"※1部位のみ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[null,null,null,null,null,"体内金属"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➡ MRI(1.5T)撮影可",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"[部位・挿入物：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"挿入時期：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"]"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※素材や留置経過期間によって検査できないことがあります。※MRI対応ペースメーカー：当院は施設基準を満たしていないため、検査できません。"]
[]
[null,null,null,null,null,"造影のみ",null,"※ガドリニウム系造影剤使用（MRI造影剤でアレルギー歴のある場合は造影検査をお引き受けできません。）"]
[]
[null,null,null,null,null,null,null,"※当日の診察で造影から単純に変更する場合があります。"]
[]
[null,null,null,null,null,null,null,"血清クレアチニン値",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,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日 測定）",null,null,null,null,null,null,null,null,"※検査予約日から3ヶ月以内の値を記載してください。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※血清クレアチニン男性1.6mg/dl 女性1.2mg/dlを超える方は、以下の理由を満たしている場合のみ造影検査をお引き受けします。［チェック必須］"]
[]
[]
[]
[]
[null,null,null,null,null,null,null,"気管支喘息"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"➡ 喘息発作または治療歴が1年以内に",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"／",null,null,null,null,null,null,null,null,null,"※造影検査をお引き受けできません。"]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※1部位のみ"]
["※複数部位選択可能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,"※禁忌事項は予約時にご確認ください。",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,null,null,null,null,null,null,"受診結果DISK",null,null,null,null,null,null,null,null,null,null,"必要",null,null,null,null,null,null,null,null,"※ご不要の場合にはご連絡ください。"]
[]
[]
[]
["ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性　別",null,null,null,null,null,"住所",null,null,null,null,"〒",null,null,null,null,null,null,null,"―"]
["患者様名",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,"様"]
[]
["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,null,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,null,null,null,null,"TEL：",null,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：",null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,"）"]
["傷病名"]
[]
[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,"部位・組織：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",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,"※スクリーニングおよび良悪鑑別は自費となります。"]
["※必ずご記入\nください。"]
[]
[]
["症状経過・\n治療経過"]
[]
[]
[]
[]
[]
["検査結果\n(病理検査・\n腫瘍ﾏｰｶｰ等)"]
[]
[]
[]
[]
[]
["既往歴"]
[]
["治 療 歴",null,null,null,null,null,null,null,null,null,"手術歴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月",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,"化学療法",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月"]
[null,null,null,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,"月",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,"年",null,null,null,null,"月"]
["職業・家族歴・現在の処方・備考"]
[]
["備考",null,null,null,"1.必要がある場合は続紙に記載して添付すること。　2.必要がある場合は画像診断のフィルム,検査の記録を添付すること。\n3.紹介先が保険医療機関以外である場合は、紹介先医療機関等名の欄に紹介先保険薬局,市町村,保険所名等を記載すること。かつ、患者住所及び電話番号を必ず記入すること。"]
["診療用放射線の安全利用に関するガイドラインにおいては、以下について患者様へご説明し、ご理解を得ることが必要とされています。\n☑ PET検査１回当たりの被ばく線量は約３mSv（ミリシーベルト）、CT検査1回当たりの被ばく線量は約２～１０mSvです。ただし、体重や撮影部位により被ばく線量は異なります。\n☑ 放射線被ばくによる不利益に比べ、検査を行う事により得られる利益が上回る場合に、当該放射線診療を実施します。\n☑ ゆうあいクリニックでは、医療被ばく低減のため、関係学会等の策定したガイドライン等を活用して線量を評価し、診療目的や画質等に関しても十分に考慮した上で、最適化を定期的に行っています。"]
["ゆうあいクリニックでの検査結果を直接依頼元の医療機関へ提供することについて患者様の同意がある場合に限り、本診療情報提供書をご利用ください。"]
["コールセンター臨床　FAX 045-548-1969 / TEL 045-540-8215"]
["予約フリーダイヤル　0120-852-026"]
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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,null,null,null,null,null,null,null,"以下の患者様の画像診断をお願い申し上げます。"]
[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,null,null,null,"予約日時：",null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(AX7), \"\", AX7)","v":""},null,null,null,null,null,null,null,"年",null,{"$f":"IF(ISBLANK(BH7), \"\", BH7)","v":""},null,null,null,"月",null,{"$f":"IF(ISBLANK(BN7), \"\", BN7)","v":""},null,null,null,"日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(CJ7), \"\", CJ7)","v":""},null,null,null,"時",null,{"$f":"IF(ISBLANK(CP7), \"\", CP7)","v":""},null,null,null,"分"]
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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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜３枚目＞"]
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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,null,null,null,null,null,null,"検査予約票"]
[]
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["■検査当日にお持ちいただくもの"]
["　　マイナ保険証（または 健康保険証）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 　　検査料金",null,null,null,null,null,null,null,null,null,null,null," 　　各種受給者証（お持ちの方のみ）"]
["　　 検査同意書",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," 　　問診票",null,null,null,null,null,null,null,null,null,null,null," 　　主治医からお預かりになった"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　・診療情報提供書（紹介状）"]
["※マイナ保険証：健康保険証の利用登録を行っているマイナンバーカード",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　・CTやMRIなどのDISK"]
["※検査当日までに「問診票」「検査同意書」をご記入ください。「問診票」「検査同意書」がお手元にない場合は、当日、受付でご用意しております。来院後、ご記入ください。"]

{"sheet":"心サル対応","index":1,"n_rows":69,"n_cols":5,"rows_kept":69,"cut":false,"hidden":true,"merged":[]}
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["▼↓通常版",null,null,null,"▼↓画像（リンクされた図）"]
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["■検査にあたってのご注意\n・予約時間の10分前にはご来院ください。\n・当クリニックでは検査結果についての説明は行いません。"]
["■PET、PET/CT検査にあたってのご注意［所要時間：約3時間］\n①予約時間の5時間前から絶食（ガム、あめも含む）、水分は水、白湯、無糖のお茶にしてください。\n　5時間以上前でも炭水化物・糖質摂取が多いと検査の精度が落ちることがありますので、通常の半分\n　以下の量にしてください。絶食ができなかった場合、検査時間、検査日を変更することがあります。\n　※水分制限のある方以外は、脱水予防のため水や無糖のお茶は多めにお摂りください。\n　　(1食には約500mLの水分があり、絶食すると水分不足になりがちです。)\n②糖尿病薬：検査当日から検査終了まで、飲み薬、インスリンは使用を中止してください。\n　（低血糖予防のためと、インスリンによる筋肉への強いFDG集積を防ぐため）\n　 ※Ⅰ型糖尿病などで、当日のインスリンを中止できない場合は事前に糖尿病でおかかりの主治医へ\n　　 絶食時間をお伝えの上ご相談ください。　　[ 絶食時間＝検査前5時間＋検査の所要時間 ]\n③糖尿病薬以外のお薬：通常通り使用してください。\n　痛み止めなども通常通り使用した上で、検査時にも使用されたい場合はお持ちください。\n④前日から検査終了まで運動はお控えください。筋肉を使うと画像の精度が落ちることがあります。"]
["■MRI検査にあたってのご注意［所要時間：約1時間］\n・MRI検査（上腹部・骨盤部）、造影MRI検査を受診する方は、上記PET、PET/CT検査\n   にあたってのご注意①②を順守してください。"]
["■CT検査（上腹部・骨盤部）、超音波検査（上腹部）にあたってのご注意［所要時間：約1時間］\n・上記PET、PET/CT検査にあたってのご注意①②を順守してください。 "]
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["※心サル対応ロゴ・チェックボックスボタンはロゴとチェックボックスのみ対応"]
["　　図は手動で入れ替えること"]
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["▼心サル対応版",null,null,null,"▼↓画像（リンクされた図）"]
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["■検査にあたってのご注意\n・予約時間の10分前にはご来院ください。\n・当クリニックでは検査結果についての説明は行いません。"]
["■ＰＥＴ、ＰＥＴ/ＣＴ検査にあたってのご注意［所要時間：約３時間］\n①予約時間の18時間前から絶食（ガム、あめも含む）、水分は水、白湯、無糖のお茶にしてください。\n※主治医から18時間を超える絶食の指示が出ている場合には、その指示に従ってください。\n　絶食前の最後のお食事は、炭水化物・糖質を摂取しないでください。\n※水分制限のある方以外は、脱水予防のため水や無糖のお茶は多めにお摂りください。\n　（1食には約５００ｍＬの水分があり、絶食すると水分不足になりがちです。）\n②糖尿病薬：予約時間の18時間前から絶食となるため、検査時間の約３時間を含めると絶食時間が\n約21時間になります。低血糖予防のため、検査の前日および当日における飲み薬、インスリンは、\n使用を中止してください。　※Ⅰ型糖尿病などで、当日のインスリンを中止できない場合は事前に\n糖尿病でおかかりの主治医へ絶食時間をお伝えの上ご相談ください。\n[ 絶食時間＝検査前18時間＋検査の所要時間 ]\n 【SGLT2阻害薬】糖尿病・慢性腎臓病での内服は中止してください。\n　心不全で使用している場合は、中止可能か循環器科主治医にご相談ください。\nなお、継続の場合は脱水にならないように十分にご注意ください。\n③糖尿病薬以外のお薬：通常通り使用してください。\n痛み止めなども通常通り使用した上で、検査時にも使用されたい場合はお持ちください。\n④前日から検査終了まで運動はお控えください。筋肉を使うと画像の精度が落ちることがあります。"]

{"sheet":"チェックラジオマスタ","index":2,"n_rows":20,"n_cols":8,"rows_kept":20,"cut":false,"hidden":true,"merged":[]}
["チェックボックス、ラジオボタンマスタ"]
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["PET/CT"]
["乳房専用PET追加","CT不要","ペースメーカー","ICDまたはCRT-D","糖 尿 病"]
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["単純MRI/造影MRI"]
["単純MRI","造影MRI","部位","体内金属","喘息","喘息発作または治療歴が1年以内"]
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["CT単純"]
["脳","頸部","胸部","上腹部","骨盤部","その他","ペースメーカー","ICDまたはCRT-D"]
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["US"]
["部位"]
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["臨床診断"]
["心筋サルコイドーシス"]