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[]
["診療情報提供書（CT検査依頼書）"]
["医療法人渓和会 江別病院",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"TODAY()","v":"2024-11-11"}]
["送付先FAX番号　011-382-2050"]
[null,null,null,null,null,null,null,null,null,null,null,null,"紹介元"]
["渓和会　江別病院　医療連携室　行",null,null,null,null,null,null,"TEL　011-382-1111",null,null,null,null,"医療機関名"]
[null,null,null,null,null,null,null,null,null,null,null,null,"郵便番号"]
["受診希望日",null,null,null,null,null,null,null,null,null,null,null,"所在地"]
["第一希望日時"]
["第二希望日時",null,null,null,null,null,null,null,null,null,null,null,"医師名"]
["別途希望があればご記入ください。",null,null,null,null,null,null,null,null,null,null,null,"連絡先",null,"TEL"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX"]
["患者状況",null,null,null,null,null,null,null,null,null,null,null,"　　　　　　　　　　　　　　　",null,null,null,null,")"]
[]
["フリガナ",null,null,null,null,null,null,null,null,null,"性別",null,"生年月日",null,null,null,null,null,null,null,"年齢",{"$f":"IF(X18<110,X18,\"\")","v":""},"歳",{"$f":"DATEDIF(O18,U6,\"Y\")","v":124}]
["患者氏名"]
[null,null,null,null,null,null,null,null,null,null,null,null,"電話番号"]
["住所"]
[]
[]
["病名（主訴）"]
[]
["病状・治療経過、検査目的（読影医に提出いたします。）"]
[]
[]
[]
[]
[]
[]
["検査種類",null,null,null,null,null,null,null,null,null,null,null,null,"CD-ROM"]
["検査部位（複数チェック可能です）"]
[1,"頭部",null,null,null,null,null,null,null,null,null,null,null,"読影\nレポート"]
[2,"頸部"]
[3,"胸部",null,null,null,null,null,null,null,null,null,null,null,"来院方法"]
[4,"腹部"]
[5,"推体",null,null,null,null,null,null,null,null,null,null,null,"その他特記事項（撮影条件など）"]
[6,"四肢"]
[]
[7,"血管"]
[]
[]
[]
["造影剤チェック項目（造影依頼時のみご記入ください）"]
["※実施に際しては下記の3項目すべての確認が必要です。下記に1項目でもチェックがない場合、造影CT検査の依頼はお受けすることが\n   できません。必要に応じ通常外来へご紹介ください。"]
[]
[]
[]
[]
[null,"全身蕁麻疹、気管支痙攣、咽頭浮腫、顔面浮腫、低血圧性ショック、アナフィラキシー様症候群、意識障害、呼吸停止、心停止"]
[]
["前投薬使用の可否（冠動脈CT依頼時のみご記入ください）"]
[null,"コアベータ注射薬：",null,null,null,null,null,null,null,"ミオコールスプレー："]
[]
["●造影CT検査の際、ビグアナイド系糖尿病治療薬は検査前後2日間（検査日を含めて5日間）の休薬を通常お願いしております。 \n　 eGFR 60以上の場合に限り、内服継続が望ましければ依頼医判断で継続も可能です。"]
[]
["●造影CT前に必ず絶食とする必要はありませんが、検査前1時間の食事は極力控えるようにご説明ください。\n　腸管や胆嚢の精査が主目的の場合は、検査3時間前から絶食としてください。飲水は可能です。"]