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["MRI検査依頼書兼診療情報提供書"]
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[null,"紹介先医療機関名：熊本市医師会熊本地域医療センター",null,null,null,null,null,null,null,null,null,null,null,null,"依頼日",null,"年",null,"月",null,"日"]
[null,null,null,"放射線部　担当医　殿"]
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[null,null,null,"紹介元医療機関の名称："]
[null,null,null,null,"所在地："]
[null,null,null,null,"電話番号：",null,null,null,null,null,null,null,null,null,null,"FAX："]
[null,null,null,null,"依頼医師氏名："]
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[null,"患者氏名：",null,null,null,null,null,null,null,null,"殿",null,null,null,null,"性別："]
[null,"患者住所：",null,null,null,null,null,null,null,null,null,null,null,null,"電話番号："]
[null,"生年月日：",null,null,"年",null,"月",null,"日","（",null,"）","歳",null,null,"職業："]
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[null,"検査日:",null,null,"年",null,"月",null,"日",null,null,null,null,null,null,"患者番号："]
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[null,"MRI検査部位  ※✓印を付けて下さい（原則、複数不可）",null,null,null,null,null,null,null,null,null,null,"＜体内金属＞ ※必ず記入して下さい（有の場合は要相談）"]
[null,"   頭部        下垂体       頚部",null,null,null,null,null,null,null,null,null,null,"心臓ペースメーカー：",null,null,null,"    無     有"]
[null,"   乳房        胸部　　　　　　　",null,null,null,null,null,null,null,null,null,null,"脳動脈クリップ：",null,null,null,"    無     有"]
[null,"   MRCP        肝臓         膵臓          腎臓　　　",null,null,null,null,null,null,null,null,null,null,"ICD･体内神経刺激装置：",null,null,null,"    無     有"]
[null,"   子宮        卵巣         前立腺        直腸",null,null,null,null,null,null,null,null,null,null,"人工内耳：",null,null,null,"    無     有"]
[null,"   頚椎        胸椎         腰椎",null,null,null,null,null,null,null,null,null,null,"歯科インプラント･矯正具：",null,null,null,"    無     有"]
[null,"   四肢","（",null,null,"）"," MRアンギオ",null,null,"（",null,"）","その他（",null,null,null,null,null,null,null,null,"）"]
[null,"   その他(",null,null,null,null,null,null,null,null,null,")","＜チェック項目＞ ※必ず記入して下さい"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"手術歴：",null,"    無     有（",null,null,null,null,null,"）"]
[null,"造影希望",null,"　　有　・　　無　・　　 一任",null,null,null,null,null,null,null,null,null,"閉所恐怖症：",null,"    無     有",null,"※重度の閉所恐怖症は要相談"]
[null,"臨床診断及び紹介目的",null,null,null,null,null,null,null,null,null,null,"腎機能 採血日：",null,null,null,null,"Cr値："]
[null,"〈 既往歴 症状経過 治療経過 現在の処方 検査結果 等 〉",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"eGFR値："]
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[null,"下記のどれか一つお選びください",null,null,null,null,null,"※ ペースメーカーはMRI対応であっても、申込み時に必ずご連絡をお願いします。"]
[null,"         CD要",null,null,null,null,null,"※ 体内金属が『有』の場合、事前にMRI対応かご確認をお願いします。"]
[null,"         フィルム要",null,null,null,null,null,"※ 女性の場合妊娠の可能性のない事を確認してください。"]
[null,"         不要",null,null,null,null,null,"※ 患者様がお薬手帳をお持ちでしたら、持参させて下さい。"]
["検査受付直通（月～金  8：30～18：00 土 8：30～13：00）  電話 096-366-1323   FAX 096-363-3416"]
["熊本市医師会　 熊本地域医療センター （ 代表 ）          電話 096-363-3311   FAX 096-362-0222"]