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["RI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："]
[]
[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,"検査部位",null,"検査の種類　　※✓印を付けて下さい"]
[null,"骨",null,"　　骨シンチ"]
[null,"肝　臓",null,"　　肝アシアロ",null,null,null,null,null,null,"その他","（",null,null,null,null,null,null,null,null,"）"]
[null,"頭　部",null,"　　脳血流（安静のみ）"]
[null,"心　臓",null,"　　心筋血流（　　安静・　　負荷）　　　心筋脂肪酸代謝　　　　　  心筋交換神経機能"]
[null,"腎　臓",null,"　　静態シンチ　　　　動態シンチ　　　　その他（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"副　腎",null,"　　髄質シンチ"]
[null,"甲状腺",null,"　　摂取率（　　123I・　　99mTC）　　　 腫瘍シンチ（99mTC-201Tl同時）　　　副甲状腺"]
[null,"腫　瘍",null,"　　67Ga",null,null,null,"その他",null,"（",null,null,null,null,null,null,null,null,null,null,"）"]
[null,"その他",null,"　　出血　　　　　 メッケル憩室　　　　 その他（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,"臨床診断及び紹介目的"]
[null,"〈 既往歴 症状経過 治療経過 現在の処方 検査結果 等 〉"]
[]
[]
[]
[]
[]
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["　　※ 女性の場合、妊娠の可能性のない事を確認してください。また、授乳中の方は事前にご相談下さい。"]
["　　※ 患者様がお薬手帳をお持ちでしたら、持参させて下さい。"]
["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"]