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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,"PET/CT","CT不要","-","-","-","乳房専用PET+PET/CT","単独検査","単純MRI","造影MRI","CT（単純）","脳","頸部","胸部","上腹部","骨盤部","その他","US","受診結果DISK"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,"C18","C10",null,null,null,"C13","C12","C14",null,"C15","C110","C111","C112","C113","C114","C115","C16","C21"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,true,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,true]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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　小澤　幸彦　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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"肺癌","大腸癌","乳癌","頭頸部癌","悪性リンパ腫","多発性骨髄腫","膵癌","子宮頸癌","子宮体癌","卵巣癌","胆嚢癌","胆管癌","肝細胞癌","食道癌","胃癌","GIST","前立腺癌","腎癌","膀胱癌","皮膚癌","軟部組織腫瘍","脳腫瘍","心筋サルコイドーシス","-","その他","病期診断","転移再発診断","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,"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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"C22","C25","C28","C32","C33","C38","C39","C23",null,"C26","C29","C31","C34","C35","C36","C41","C40",null,null,"C24","C27","C30","C346",null,"C42","C43","C44","C45"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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",null,null,null,null,false]
[]
["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）\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,null,null,"-","MRI","US","PEM","-","-","性別","生年月日","手術歴1","手術歴2","化学療法","放射線治療","糖 尿 病","3ヶ月以内のG-CSFの使用","ﾍﾟｰｽﾒｰｶｰ","体内金属","人工肛門","気管切開","妊　娠","感染症","喘　息","ｱﾚﾙｷﾞｰ","現在状況","30分静止","経口摂取","自力歩行"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"G2","G3","G4",null,null,"G9","G10","G11","G12","G13","G14","G15","G16","G17","G18","G19","G20","G21","G22","G23","G24","G25","G26","G27","G28"]
["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、US検査を一つ以上追加した場合、「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,"（頭頂部から大腿基部まで）",null,null,null,null,null,null,null,null,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。"]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,null,null,null,null,"）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※検査予約日から3ヶ月以内の値を\n　　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,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,"mg/dl",null,null,null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日 測定）"]
[]
[]
["※ガドリニウム系造影剤使用",null,null,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を超える場合や気管支喘息の場合は左記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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["　　　　　※複数部位選択可能"]
[]
[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,null,null,null,null,null,"　"]
["受診結果DISK",null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",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,"）"]
["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,null,null,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,"※スクリーニングおよび良悪鑑別は自費となります。"]
["病理検査・\n腫瘍ﾏｰｶｰ・\n臨床経過等\n\n※必ずご記入\nください。"]
[]
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["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,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,"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,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,"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"]
["糖 尿 病",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,null,null,null,"3ヶ月以内のG-CSFの使用"]
[null,null,null,null,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,"薬剤名",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,"最終使用日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,null,null,"日"]
["ﾍﾟｰｽﾒｰｶｰ",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,"妊　娠",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"現在状況"]
["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,null,null,null,null,"）",null,"感染症",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）",null,"30分静止"]
["人工肛門",null,null,null,null,null,null,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",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"経口摂取",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）"]
["気管切開",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）",null,"ｱﾚﾙｷﾞｰ",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,"自力歩行"]
["持込画像は、データ（DISK）のみお受けいたします。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受診者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。なお、特別な取扱いが必要な場合には、下記の電話番号へご連絡ください。"]
["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"]
["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,"＜２枚目＞"]
[{"$f":"IF(ISBLANK(A2), \"\", A2)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ご紹介元医療機関控"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療情報提供書（画像診断依頼書）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ゆうあいクリニック　小澤　幸彦　先生"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以下の患者様の画像診断をお願い申し上げます。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"予約日時：",null,null,null,null,null,null,null,null,{"$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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["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,"＜３枚目＞"]
[{"$f":"IF(ISBLANK(A2), \"\", A2)","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査予約票"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"予約日時：",null,null,null,null,null,null,null,null,{"$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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["■検査当日にお持ちいただくもの"]
[]
[" 健康保険証、各種受給者証\n（高齢受給者証など）",null,null,null,null,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・検査同意書\n（検査当日までにご記入ください）"]
["主治医からお預かりになった診療情報提供書（紹介状）、CTやMRIなどのDISK",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," \n検査料金"]
[]
[]
["■検査にあたってのご注意\n・予約時刻の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検査に当たってのご注意\n①ご予約時間の５時間前から絶食してください（水・無糖のお茶は可）\n②検査当日は糖尿病のお薬（飲み薬・注射薬）の使用を中止してください。\n③検査前日から、下剤（酸化マグネシウム、マグラックスを除く）の服用を\n中止してください。\n④検査前日から運動はお避け下さい。\n⑤まれに検査終了時間が１時間ほど延長となる場合があります。　　　　　　"]
[]
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["■MRI検査にあたってのご注意\n・体内に以下の金属を埋め込んだことのある方は事前にお申し出ください。\n　心臓ペースメーカー・血管等ステント・脳動脈瘤等クリップ・人工内耳・人工関節・その他金属\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検査に当たってのご注意①②を順守してください。\n\n■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\n・上記PET検査に当たってのご注意①②を順守してください。 "]