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["診療情報提供書（MRI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,{"$f":"TODAY()","v":"2024-11-11"}]
["送付先FAX番号　011-382-2050"]
[null,null,null,null,null,null,null,null,null,null,null,null,"紹介元"]
["渓和会　江別病院　医療連携室　行",null,null,null,null,null,null,"TEL　011-382-1111",null,null,null,null,"医療機関名"]
[null,null,null,null,null,null,null,null,null,null,null,null,"郵便番号",null,"〒"]
["受診希望日",null,null,null,null,null,null,null,null,null,null,null,"所在地"]
["第一希望日時"]
["第二希望日時",null,null,null,null,null,null,null,null,null,null,null,"医師名"]
["別途希望があればご記入ください。",null,null,null,null,null,null,null,null,null,null,null,"連絡先",null,"TEL"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX"]
["患者状況",null,null,null,null,null,null,null,null,null,null,null,"　　　　　　　　　　　　　　　",null,null,null,null,"）"]
[]
["フリガナ",null,null,null,null,null,null,null,null,null,"性別",null,"生年月日",null,null,null,null,null,null,null,"年齢",{"$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。）"]
[]
[]
[]
[]
[]
[]
["検査部位",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"CD-ROM"]
[1,"頭部"]
[2,"胸部",null,null,null,null,null,null,null,null,null,null,null,null,null,"読影\nレポート",null,null,"（後日、郵送またはお届けいたします）"]
[3,"上腹部"]
[4,"下腹部",null,null,null,null,null,null,null,null,null,null,null,null,null,"来院方法"]
[5,"上肢","【　　     　　　】"]
[6,"下肢","【　　　     　　】",null,null,null,null,null,null,null,null,null,null,null,null,"その他特記事項（撮影条件など）"]
[7,"椎体"]
[8,"心血管"]
[9,"その他"]
["MRIチェック項目（必ずご記入ください）"]
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[]
[]
["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できません。"]
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["腹部MRCP検査の際は下記の通りに説明をお願いいたします。\n・当日は水またはお茶とし、検査3時間前から内服以外の水分は取らないでください\n・午前検査の方：朝食は食べないでください。服薬中の内服薬は朝7時までに少量の水で内服してください。\n・午後検査の方：午前8時までに軽い食事を済ませ、昼食は食べないでください。服薬中の内服薬は昼12時までに少量の水で\n　内服してください。"]