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["X線CT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"]
[]
[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："]
[]
[null,"検査日:",null,null,"年",null,"月",null,"日",null,null,null,null,null,null,"患者番号："]
[]
[null,"CT検査部位  ※✓印を付けて下さい（複数選択可）",null,null,null,null,null,null,null,null,null,null,null,"※ ヨード造影剤副作用歴"]
[null,"    頭部         副鼻腔",null,null,null,null,null,null,null,null,null,null,null,null,"    無 ・    有 ・    使用歴無（不明）"]
[null,"    頚部         胸部         腹部         骨盤",null,null,null,null,null,null,null,null,null,null,null,null,"造影剤："]
[null,"    上肢         下肢",null,null,null,null,null,null,null,null,null,null,null,null,"症  状："]
[null,"造影希望",null,"      有  ・      無  ・      一任",null,null,null,null,null,null,null,null,null,"※ 腎 機 能",null,"(採血日：",null,null,null,null,null,")"]
[null,"臨床診断及び紹介目的",null,null,null,null,null,null,null,null,null,null,null,null,"クレアチニン値："]
[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,"(eGFR値：",null,null,null,null,null,")"]
[null,"       　　　　　　　　　　　　　              ",null,null,null,null,null,null,null,null,null,null,null,"※ ビグアナイド系糖尿病薬の服用"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"  無 ・  有（薬剤名：",null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"※ 現在治療中の気管支喘息"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"  無 ・  有（最終発作：",null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"〈 検査範囲 〉※頭部以外の場合図示して下さい"]
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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,"※ 女性の場合妊娠の可能性のない事を確認してください。                           ※ 3D-CT等ご希望の際は、申込時にお伝えください。                                ※ 心臓（冠動脈等）CTをご希望の場合は、循環器内科へご相談下さい。                ※ 胸部検査の場合は、胸部写真を持参させて下さい。                                       ※ 患者様がお薬手帳をお持ちでしたら、持参させて下さい。 "]
[null,"          CD 要"]
[null,"          フィルム要"]
[null,"          不要"]
["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"]