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{"sheet":"☆ 診療情報提供書兼CT・MRI　申込書","index":0,"n_rows":55,"n_cols":85,"rows_kept":55,"cut":false,"hidden":false,"merged":[[54,34,54,38],[33,21,33,26],[44,30,44,33],[7,1,7,7],[52,1,53,4],[52,5,52,7],[52,9,52,14],[52,16,52,38],[53,5,53,7],[53,9,53,14],[53,16,53,38],[49,5,49,11],[49,13,49,14],[49,17,49,38],[50,5,50,11],[50,13,50,14],[50,17,50,38],[46,7,46,14],[46,18,46,38],[47,5,47,11],[47,13,47,14],[47,17,47,38],[48,5,48,11],[48,13,48,14],[48,17,48,38],[41,1,50,4],[41,5,46,6],[41,7,41,23],[41,28,41,38],[42,7,42,23],[42,28,43,37],[43,7,43,23],[44,7,44,23],[45,7,45,23],[38,1,39,4],[38,5,38,8],[38,12,38,18],[38,19,38,30],[39,5,39,8],[39,12,39,23],[39,25,39,37],[29,35,29,37],[31,1,36,2],[31,3,31,4],[32,3,36,4],[34,6,34,10],[34,11,34,21],[34,27,34,37],[35,6,35,38],[36,6,36,38],[34,25,34,26],[38,32,38,36],[27,1,27,4],[27,5,27,38],[29,1,29,4],[29,6,29,7],[29,10,29,11],[29,14,29,16],[29,17,29,26],[29,27,29,28],[29,29,29,31],[29,33,29,34],[23,1,24,4],[23,5,24,38],[25,1,25,4],[25,5,25,38],[26,1,26,4],[26,5,26,38],[20,36,21,38],[21,1,22,4],[21,5,22,16],[21,17,22,22],[21,23,22,24],[21,25,22,27],[21,28,22,35],[22,36,22,38],[20,1,20,4],[20,5,20,16],[20,17,20,22],[20,23,20,24],[20,25,20,27],[20,28,20,35],[16,9,16,12],[16,18,16,19],[16,23,17,25],[16,26,17,38],[18,9,18,12],[18,18,18,19],[18,23,19,25],[18,26,19,38],[14,1,14,2],[14,3,14,5],[14,9,14,12],[14,18,14,19],[14,23,15,25],[14,26,15,38],[9,1,9,7],[9,8,9,38],[10,8,10,38],[12,1,12,8],[12,9,12,22],[12,23,13,25],[12,26,13,38],[4,1,5,17],[4,20,4,25],[4,31,5,38],[5,20,5,25],[7,8,7,38]]}
[]
[null,"※",null,"の部分はプルダウン形式で入力できます。"]
[null,"※","このシートは保護してあるため、選択できるセルが限られています。「校閲」の「シートの保護の解除」より解除出来ます。"]
[]
[null,"診療情報提供書 兼 CT・MRI　申込書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査申込日　　",null,null,null,null,null,null,null,null,null,null,"伊万里有田共立病院"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"TODAY()","v":"2024-06-06"}]
[]
[null,"① 単純検査の場合　・・・　",null,null,null,null,null,null,"こちらの申込書にて放射線科 FAX 0955-41-2630 、又は電話予約 0955-46-2121（内線1145）　をお願いします。"]
[]
[null,"② 造影検査の場合　・・・　",null,null,null,null,null,null,"別紙 [診療情報提供書] を地域医療連携室へ ＦＡＸ 0955-46-2160 　をお願いします。"]
[null,null,null,null,null,null,null,null,"診療各科ご紹介の後に、造影検査を施行いたします。その際、放射線科への予約は不要です。"]
[]
[null,"検査決定日時",null,null,null,null,null,null,null,"検査の希望日",null,null,null,null,null,null,null,null,null,null,null,null,null,"医療機関名"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31]
[null,"（西暦）",null,null,null,null,"年",null,null,"第一希望",null,null,null,null,null,"月",null,"日",{"$f":"IFERROR(WEEKDAY(D15&\"/\"&O15&\"/\"&Q15,1),\" \")","v":" "},null,null,null,"時","所在地",null,null,null,null,null,null,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]
[null,null,null,null,null,null,"月",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,3]
[null,null,null,null,null,null,null,null,null,"第二希望",null,null,null,null,null,"月",null,"日",{"$f":"IFERROR(WEEKDAY(D15&\"/\"&O17&\"/\"&Q17,1),\" \")","v":" "},null,null,null,"時","TEL/FAX",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,4]
[null,null,null,null,"時",null,"分",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,5]
[null,null,null,null,null,null,null,null,null,"都合が悪い日",null,null,null,null,null,"月",null,"日",{"$f":"IFERROR(WEEKDAY(D15&\"/\"&O19&\"/\"&Q19,1),\" \")","v":" "},null,null,null,"時","医師名",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,6]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,7]
[null,"フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日　(西暦/月/日)",null,null,null,null,null,"性別",null,null,null,null,"電話番号 （連絡のつきやすいもの）",null,null,null,null,null,null,null,"自宅/携帯",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,8]
[null,"患者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年齢",null,{"$f":"DATEDIF(R22,U6,\"y\")&\"歳\"","v":"124歳"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,9]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,10]
[null,"住所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,11]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,12]
[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,"右",null,null,null,null,null,"CD-R （DICOM)",null,null,null,null,null,null,null,null,null,"男",null,null,"自宅"]
[null,"臨床診断・検査の主眼点",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左",null,null,null,null,null,"フィルム",null,null,null,null,null,null,null,null,null,"女",null,null,"携帯"]
[null,"既往歴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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","可",null,null,null,"要","不要",null,null,null,null,null,null,null,null,null,"午前"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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","不可",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"午後"]
[null,"検査種別",null,null,null,"□","CT",null,null,"□","MRI",null,null,"□","骨密度",null,null,"※単純検査のみ承ります",null,null,null,null,null,null,null,null,null,"身長",null,null,null,null,"ｃｍ","体重",null,null,null,null,"ｋｇ"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□"]
[null,"撮影部位　",null,"CT",null,"□","頭部　　",null,null,"□","頚部",null,null,"□","胸部",null,null,"□","上腹部",null,null,"□","骨盤腔",null,null,"□","脊椎",null,null,"□","四肢",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"☑",null,0,10,20,30,40,50]
[null,null,null,"MR",null,"□","脳",null,null,"□","頚部",null,null,"□","胸部",null,null,"□","上腹部",null,null,"□","MRCP",null,null,"□","骨盤腔",null,null,"□","股関節"]
[null,null,null,null,null,"□","頚椎",null,null,"□","胸椎",null,null,"□","腰椎",null,null,"□","四肢",null,"（",null,null,null,null,null,null,"）","（",null,"）"]
[null,null,null,null,null,"□","軟部腫瘤　（部位：",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,"□","全身転移検索（頭部～骨盤）　　※ がんの再発・転移検索を目的とされる際にご依頼ください。"]
[null,null,null,null,null,"□","不明熱原因検索（頭部～骨盤） ※ CT等で原因が特定できなかった際にご依頼ください。"]
[]
[null,"患者情報",null,null,null,"◆体内金属",null,null,null,"（",null,"）","金属の部位［",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"］","◆妊娠の可能性 （",null,null,null,null,null,"）"]
[null,null,null,null,null,"◆感染症",null,null,null,"（",null,"）","※「有」の場合は詳細を記入お願いします。",null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,"MR確認事項",null,null,null,"体内金属",null,"◆ペースメーカーやMR禁忌の体内機器",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,"）",null,"※　「有」の場合検査施行できません。"]
[null,null,null,null,null,null,null,"◆脳動脈瘤クリップや、その他の血管クリップ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,"）",null,"有りの場合、MRI検査可能である事の確認をお願いします。"]
[null,null,null,null,null,null,null,"◆体内留置物（心臓人工弁、ステント、コイル）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,"）"]
[null,null,null,null,null,null,null,"◆外科・整形外科的術後金属",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,"）",null,null,null,"確認済　",null,null,null,"□"]
[null,null,null,null,null,null,null,"◆磁気インプラント ・ 可動式義眼 ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,"）"]
[null,null,null,null,null,null,null,"◆シャントバルブ",null,null,null,null,null,null,null,"（",null,"）","※「有」は検査後の確認調整のため脳神経外科の受診もお願いします。"]
[null,null,null,null,null,"◆刺青やアートメイク ",null,null,null,null,null,null,"（",null,null,"）",null,"※　変色や火傷の可能性がありますので、患者様の同意を得て下さい。"]
[null,null,null,null,null,"◆閉所恐怖症",null,null,null,null,null,null,"（",null,null,"）",null,"※　「有」で内服薬が必要な際は貴院での処方をお願いします。"]
[null,null,null,null,null,"◆妊娠",null,null,null,null,null,null,"（",null,null,"）",null,"※　妊娠16週以降の検査が推奨されています。"]
[null,null,null,null,null,"◆血糖値測定器",null,null,null,null,null,null,"（",null,null,"）",null,"※　「有」の場合は装着期間を考慮した予約をお願いします。"]
[]
[null,"検査結果",null,null,null,"◆ 画像",null,null," 【",null,null,null,null,null,null,"】","※画像は検査終了後、患者様にお渡しします。"]
[null,null,null,null,null,"◆ 読影",null,null," (",null,null,null,null,null,null,"）","※読影結果はFAXにて報告させていただきます。"]
[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,"2024年2月　改訂"]