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{"sheet":"ＧＦ検査依頼書","index":0,"n_rows":32,"n_cols":21,"rows_kept":32,"cut":false,"hidden":false,"merged":[[4,10,4,11],[4,12,4,15],[4,17,4,20],[4,0,4,1],[5,10,5,11],[5,12,5,20],[7,11,8,12],[7,0,7,1],[0,0,0,20],[1,0,1,2],[1,3,1,4],[2,10,2,11],[2,12,2,20],[2,0,2,1],[7,8,8,8],[8,0,8,1],[3,10,3,11],[3,12,3,20],[7,2,7,7],[8,2,8,7],[6,0,6,2],[3,0,3,1],[9,0,10,1],[10,2,10,10],[23,1,23,19],[12,15,12,20],[10,13,10,20],[15,0,17,5],[15,9,15,20],[16,9,16,20],[17,9,17,20],[20,0,20,5],[21,0,21,5],[11,0,11,3],[9,11,10,12],[9,13,9,20],[9,2,9,10],[31,0,33,14],[24,0,24,1],[12,0,12,3],[12,5,12,11],[13,0,14,5],[18,0,18,5],[19,0,19,5],[13,7,13,8],[14,7,14,8],[12,12,12,13],[25,1,25,19],[27,1,28,19],[29,0,29,3],[29,10,29,12]]}
["【上部消化管内視鏡検査】　検査依頼書/診療情報提供書"]
["検査申込日",null,null,null,null,"年",null,"月",null,"日"]
["検査希望日",null,null,null,null,null,null,null,null,null," 医療機関名"]
["第一希望",null,null,"月",null,"日","(　　)","平日午前",null,null," 所在地"]
["第二希望",null,null,"月",null,"日","(　　)","平日午前",null,null," TEL/FAX",null,null,null,null,null,"／"]
["※検査枠が限られている為、当院にて時間指定させていただきます",null,null,null,null,null,null,null,null,null," 医師名"]
["患者基本情報"]
["フリガナ",null,null,null,null,null,null,null,"性別",null,"男","生年\n月日",null,null,"大正",null,"昭和",null,"平成",null,"令和"]
["患者\n氏名",null,null,null,null,null,null,null,null,null,"女",null,null,null,"年",null,"月",null,"日",null,"才"]
["住所",null,null,null,null,null,null,null,null,null,null,"ＴＥＬ"]
[]
["検査依頼／診療情報"]
["検査項目",null,null,null,null,"上部消化管内視鏡検査（スクリーニング）",null,null,null,null,null,null,"結果報告\n方法",null,null,"後日郵送（1週間以内）"]
["検査方法",null,null,null,null,null,null,"経口から",null,"　※　鼻に疾患がある方や、鼻出血しやすい方は対応できません"]
[null,null,null,null,null,null,null,"経鼻から",null,"　※　抗凝固・血小板薬服用中の方は対応できません"]
["鎮静剤の使用",null,null,null,null,null,null,"使用しない",null,"　※　使用する場合、鎮静剤使用の同意書の記入をお願いいたします。"]
[null,null,null,null,null,null,null,"使用する",null,"　※　当日車運転しての来院不可。公共交通機関や送迎で来院して下さい。"]
[null,null,null,null,null,null,null,null,null,"　※　閉塞性緑内障の方は、鎮静剤を使用できません"]
["抗凝固剤の確認",null,null,null,null,null,null,"内服なし",null,null,null,"内服あり（下段の休薬確認へ）"]
["抗凝固剤休薬の確認",null,null,null,null,null,null,"継続",null,null,null,"中止","（",null,"月",null,"日","～　中止",null,"）"]
["抗血小板剤の確認",null,null,null,null,null,null,"内服なし",null,null,null,"内服あり（下段の休薬確認へ）"]
["抗血小板剤休薬の確認",null,null,null,null,null,null,"継続",null,null,null,"中止","（",null,"月",null,"日","～　中止",null,"）"]
["【検査目的】"]
[]
["【臨床診断】"]
[]
["【他依頼 等】"]
[]
[]
["【自院での検査レポート】",null,null,null,null,"あり",null,null,"なし",null,"【自院での画像】",null,null,null,"あり",null,null,"なし"]
["※ありの場合はその他書類と一緒にFAXをお願いいたします。",null,null,null,null,null,null,null,null,null,"※ありの場合は当日ご持参ください。"]
["地域医療連携室　連絡先\n《　ＦＡＸ　０４３－４８６－１８０７　》\n《　ＴＥＬ　０４３－４８６－５５１１　》\nお問い合わせ　月-金　8:30-17:00　／　土　8:30-12:00　（年末年始・祝日除く）"]

{"sheet":"（案）CT","index":1,"n_rows":34,"n_cols":21,"rows_kept":34,"cut":false,"hidden":true,"merged":[[7,14,7,15],[8,2,8,6],[10,10,10,13],[3,0,3,2],[3,10,3,11],[3,12,3,20],[4,0,4,1],[4,10,4,11],[4,12,4,15],[4,17,4,20],[5,0,5,1],[5,10,5,11],[5,12,5,20],[7,0,7,1],[7,10,7,12],[8,0,8,1],[0,0,0,20],[1,0,1,2],[1,3,1,4],[2,10,2,11],[2,12,2,20],[8,10,8,12],[7,2,7,6],[7,7,8,7],[12,10,12,12],[13,2,13,9],[9,0,10,1],[9,10,9,12],[11,0,11,1],[11,2,11,9],[11,10,11,12],[17,0,24,1],[13,15,13,16],[13,19,13,20],[15,0,16,1],[15,3,15,11],[15,12,16,13],[16,15,16,20],[16,3,16,4],[16,6,16,7],[16,8,16,9],[16,10,16,11],[12,0,13,1],[12,2,12,9],[24,15,24,19],[19,6,19,8],[20,10,24,10],[33,0,35,14],[13,10,13,14],[17,2,19,2],[20,4,20,9],[21,4,21,9],[22,4,22,9],[23,4,23,6],[24,4,24,6],[21,12,21,14],[17,10,19,10],[26,1,26,14],[27,0,27,1],[28,1,28,14],[30,1,32,14],[20,2,24,2],[19,4,19,5],[9,13,9,16],[9,17,9,20],[23,12,23,14],[21,15,21,19],[22,15,22,19],[23,15,23,19],[15,15,15,20]]}
["【ＣＴ検査】　検査依頼書/診療情報提供書"]
["検査申込日",null,null,null,null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null," 医療機関名"]
["検査希望日",null,null,null,null,null,null,null,null,null," 所在地"]
["第一希望",null,null,"月",null,"日","(　　)",null,"時","台"," TEL/FAX",null,null,null,null,null,"／"]
["第二希望",null,null,"月",null,"日","(　　)",null,"時","台"," 医師名"]
["患者基本情報"]
["フリガナ",null,null,null,null,null,null,"性別",null,"男","保険情報",null,null,null,"健康保険証",null,"／","交通事故",null,null,"労災"]
["患者\n氏名",null,null,null,null,null,null,null,null,"女","保険証番号"]
["生年\n月日",null,null,"大正",null,"昭和",null,"平成",null,"令和","被保険者証\n記号・番号"]
[null,null,null,"年",null,"月",null,"日",null,"才","被保険者との続柄",null,null,null,null,"本人",null,"家族","／","事故・労災"]
["住所",null,null,null,null,null,null,null,null,null,"公費負担番号"]
["ＴＥＬ",null,null,null,null,null,null,null,null,null,"公費負担医療の\n受給者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"負担割合",null,null,"割","負担"]
["検査依頼／診療情報"]
["造影検査\nの有無",null,null,"単純のみ",null,null,null,null,null,null,null,null,"画像郵送方法",null,null,"後日郵送（1週間以内）"]
[null,null,null,"造影検査",null,"Cr：",null,null,"eGFR：",null,null,null,null,null,null,"当日患者渡し * 読影レポートは後日郵送"]
["検査項目",null,"頭　部",null,"頭部",null,null,null,"眼窩",null,"脊 椎",null,"頸椎"]
[null,null,null,null,"副鼻腔",null,null,null,"頚部",null,null,null,"腰椎"]
[null,null,null,null,"その他（",null,null,null,null,"）",null,null,"胸椎"]
[null,null,"胸部／腹部／骨盤腔",null,"胸部（肺野・縦隔）",null,null,null,null,null,"関　節　／　他",null,"股関節"]
[null,null,null,null,"腹部（肝臓上緑から腎下極まで）",null,null,null,null,null,null,null,"上肢（部位：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"骨盤腔（第3腰椎下緑から坐骨まで）",null,null,null,null,null,null,null,"（撮影範囲：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"腹部から骨盤腔",null,null,null,null,null,null,null,"上肢（部位：",null,null,null,null,null,null,null,"）"]
[null,null,null,null,"胸部から骨盤腔",null,null,null,null,null,null,null,"（撮影範囲：",null,null,null,null,null,null,null,"）"]
["【検査目的】"]
[]
["【臨床診断】"]
[]
["【撮影指示 等】"]
[]
[]
[]
["地域医療連携室　連絡先\n《　ＦＡＸ　０４３－４８６－１８０７　》\n《　ＴＥＬ　０４３－４８６－５５１１　》\nお問い合わせ　月-金　8:30-17:00　／　土　8:30-12:00　（年末年始・祝日除く）"]

{"sheet":"（案）MRI","index":2,"n_rows":35,"n_cols":21,"rows_kept":35,"cut":false,"hidden":true,"merged":[[15,0,16,1],[16,3,16,4],[2,10,2,11],[12,0,13,1],[8,0,8,1],[7,0,7,1],[10,10,10,13],[3,0,3,2],[5,10,5,11],[4,0,4,1],[5,0,5,1],[3,10,3,11],[4,10,4,11],[8,10,8,12],[13,2,13,9],[13,10,13,11],[13,15,13,16],[13,19,13,20],[11,2,11,9],[13,12,13,13],[15,3,15,11],[15,12,16,13],[15,15,15,20],[16,15,16,20],[16,6,16,7],[16,8,16,9],[16,10,16,11],[8,2,8,6],[7,14,7,15],[7,7,8,7],[12,10,12,12],[11,10,11,12],[0,0,0,20],[1,0,1,2],[1,3,1,4],[12,2,12,9],[7,10,7,12],[2,12,2,20],[3,12,3,20],[4,12,4,15],[4,17,4,20],[5,12,5,20],[9,0,10,1],[11,0,11,1],[9,17,9,20],[9,10,9,12],[9,13,9,16],[7,2,7,6],[34,0,36,14],[27,1,27,14],[29,1,29,14],[31,1,33,14],[25,4,25,6],[25,7,25,10],[25,13,25,15],[25,16,25,19],[17,0,25,1],[21,2,25,2],[28,0,28,1],[17,2,20,2],[20,12,20,20],[18,17,18,20],[17,12,17,15],[18,14,18,15],[20,4,20,5],[20,6,20,8],[19,10,20,10],[17,10,18,10]]}
["【ＭＲＩ検査】　検査依頼書/診療情報提供書"]
["検査申込日",null,null,null,null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null," 医療機関名"]
["検査希望日",null,null,null,null,null,null,null,null,null," 所在地"]
["第一希望",null,null,"月",null,"日","(　　)",null,"時","台"," TEL/FAX",null,null,null,null,null,"／"]
["第二希望",null,null,"月",null,"日","(　　)",null,"時","台"," 医師名"]
["患者基本情報"]
["フリガナ",null,null,null,null,null,null,"性別",null,"男","保険情報",null,null,null,"健康保険証",null,"／","交通事故",null,null,"労災"]
["患者\n氏名",null,null,null,null,null,null,null,null,"女","保険証番号"]
["生年\n月日",null,null,"大正",null,"昭和",null,"平成",null,"令和","被保険者証\n記号・番号"]
[null,null,null,"年",null,"月",null,"日",null,"才","被保険者との続柄",null,null,null,null,"本人",null,"家族","／","事故・労災"]
["住所",null,null,null,null,null,null,null,null,null,"公費負担番号"]
["ＴＥＬ",null,null,null,null,null,null,null,null,null,"公費負担医療の\n受給者番号"]
[null,null,null,null,null,null,null,null,null,null,"体重",null,null,null,"㎏","負担割合",null,null,"割","負担"]
["検査依頼／診療情報"]
["造影検査\nの有無",null,null,"単純のみ",null,null,null,null,null,null,null,null,"画像郵送方法",null,null,"後日郵送（1週間以内）"]
[null,null,null,"造影検査",null,"Cr：",null,null,"eGFR：",null,null,null,null,null,null,"当日患者渡し * 読影レポートは後日郵送"]
["検査項目",null,"頭　部",null,"頭部MRA・頚部MRA",null,null,null,null,null,"腹部／\n骨盤部",null,"肝・胆・膵（MRCP）",null,null,null,null,"腎臓"]
[null,null,null,null,"VSRAD",null,null,null,"眼窩",null,null,null,"膀胱",null,"前立腺",null,null,"婦人科（子宮・卵巣）"]
[null,null,null,null,"副鼻腔",null,null,null,"頚部",null,"脊　椎",null,"頸椎",null,null,"胸椎",null,null,"腰椎"]
[null,null,null,null,"その他（",null,null,null,null,"）",null,null,"胸腰椎移行部（第8胸椎～第5腰椎まで）"]
[null,null,"関　節　／　他","　肩関節（",null,null,"右",null,"左　　）",null,null,null,"　股関節（",null,null,"右",null,"左　　）"]
[null,null,null,"　肘関節（",null,null,"右",null,"左　　）",null,null,null,"　膝関節（",null,null,"右",null,"左　　）"]
[null,null,null,"　手関節（",null,null,"右",null,"左　　）",null,null,null,"　足関節（",null,null,"右",null,"左　　）"]
[null,null,null,"　手　　　（",null,null,"右",null,"左　　）",null,null,null,"　足　　　（",null,null,"右",null,"左　　）"]
[null,null,null,null,"上肢その他（",null,null,null,null,null,null,"）",null,"下肢その他（",null,null,null,null,null,null,"）"]
["【検査目的】"]
[]
["【臨床診断】"]
[]
["【撮影指示 等】"]
[]
[]
[]
["地域医療連携室　連絡先\n《　ＦＡＸ　０４３－４８６－１８０７　》\n《　ＴＥＬ　０４３－４８６－５５１１　》\nお問い合わせ　月-金　8:30-17:00　／　土　8:30-12:00　（年末年始・祝日除く）"]

{"sheet":"（案）核医学","index":3,"n_rows":33,"n_cols":21,"rows_kept":33,"cut":false,"hidden":true,"merged":[[16,3,16,8],[7,14,7,15],[8,2,8,6],[10,10,10,13],[3,12,3,20],[3,0,3,2],[3,10,3,11],[9,17,9,20],[13,19,13,20],[15,0,16,1],[12,0,13,1],[12,2,12,9],[12,10,12,12],[13,2,13,9],[13,10,13,14],[13,15,13,16],[4,0,4,1],[4,10,4,11],[4,12,4,15],[4,17,4,20],[8,0,8,1],[8,10,8,12],[7,2,7,6],[7,7,8,7],[5,0,5,1],[5,10,5,11],[5,12,5,20],[7,0,7,1],[7,10,7,12],[0,0,0,20],[1,0,1,2],[1,3,1,4],[2,10,2,11],[2,12,2,20],[32,0,34,14],[17,0,23,1],[23,3,23,5],[25,1,25,14],[26,0,26,1],[27,1,27,14],[29,1,31,14],[20,5,20,9],[20,14,20,18],[19,3,19,5],[20,3,20,4],[21,3,21,5],[23,11,23,19],[9,13,9,16],[15,3,15,8],[11,0,11,1],[11,2,11,9],[11,10,11,12],[9,0,10,1],[9,10,9,12]]}
["【核医学検査】　検査依頼書/診療情報提供書"]
["検査申込日",null,null,null,null,"年",null,"月",null,"日"]
[null,null,null,null,null,null,null,null,null,null," 医療機関名"]
["検査希望日",null,null,null,null,null,null,null,null,null," 所在地"]
["第一希望",null,null,"月",null,"日","(　　)",null,"時","台"," TEL/FAX",null,null,null,null,null,"／"]
["第二希望",null,null,"月",null,"日","(　　)",null,"時","台"," 医師名"]
["患者基本情報"]
["フリガナ",null,null,null,null,null,null,"性別",null,"男","保険情報",null,null,null,"健康保険証",null,"／","交通事故",null,null,"労災"]
["患者\n氏名",null,null,null,null,null,null,null,null,"女","保険証番号"]
["生年\n月日",null,null,"大正",null,"昭和",null,"平成",null,"令和","被保険者証\n記号・番号"]
[null,null,null,"年",null,"月",null,"日",null,"才","被保険者との続柄",null,null,null,null,"本人",null,"家族","／","事故・労災"]
["住所",null,null,null,null,null,null,null,null,null,"公費負担番号"]
["ＴＥＬ",null,null,null,null,null,null,null,null,null,"公費負担医療の\n受給者番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"負担割合",null,null,"割","負担"]
["検査依頼／診療情報"]
["画像郵送方法",null,null,"後日郵送（1週間以内）"]
[null,null,null,"当日患者渡し * 読影レポートは後日郵送"]
["検査項目",null,null,"骨シンチ"]
[null,null,null,"脳シンチ　ＤＡＴ",null,null,null,null,null,null,null,null,"ＭＩＢＧシンチ"]
[null,null,null,"　併用注意薬（",null,null,null,"有",null,"無","）",null,"　併用注意薬（",null,null,null,"有",null,"無","）","ﾁｪｯｸ外し"]
[null,null,null,"　薬剤名（",null,null,null,null,null,null,"）",null,"　薬剤名（",null,null,null,null,null,null,"）"]
[null,null,null,"　30分仰臥位（",null,null,null,"可",null,"不可","）",null,"　15分仰臥位（",null,null,null,"可",null,"不可","）","ﾁｪｯｸ外し"]
[null,null,null,"脳血流シンチ　ＩＭＰ"]
[null,null,null,"　30分仰臥位（",null,null,null,"可",null,"不可","）","※　全て指定の仰臥位時間が保てなければ検査実施できません",null,null,null,null,null,null,null,null,"ﾁｪｯｸ外し"]
["【検査目的】"]
[]
["【臨床診断】"]
[]
["【撮影指示 等】"]
[]
[]
[]
["地域医療連携室　連絡先\n《　ＦＡＸ　０４３－４８６－１８０７　》\n《　ＴＥＬ　０４３－４８６－５５１１　》\nお問い合わせ　月-金　8:30-17:00　／　土　8:30-12:00　（年末年始・祝日除く）"]