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["この欄は貴院IDのご記入・エンボス印字等にご利用ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜１枚目＞",null,null,"PET/CT","CT不要","CT（単純）","脳","頸部","胸部","上腹部","骨盤部","その他","受診結果DISK"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ゆうあいクリニック台場宛",null,null,true,null,null,null,null,null,null,null,null,true]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療情報提供書（画像診断依頼書）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"肺癌","大腸癌","乳癌","頭頸部癌","悪性リンパ腫","白血病","膵癌","子宮頸癌","子宮体癌","卵巣癌","胆嚢癌","胆管癌","肝細胞癌","食道癌","胃癌","GIST","前立腺癌","腎癌","膀胱癌","皮膚癌","軟部組織腫瘍","脳腫瘍","心筋サルコイドーシス","ヘパリンの使用可/使用不可","その他","病期診断","転移再発診断","その他","CT","MRI","US","MMG","RI","単純X線","その他","無し"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ゆうあいクリニック台場　片山　敦　先生"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以下の患者様の画像診断をお願い申し上げます。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"午前/午後","性別","生年月日","手術歴1","手術歴2","化学療法","放射線治療","糖 尿 病","1ヶ月以内のG-CSFの使用","ﾍﾟｰｽﾒｰｶｰ","体内金属","人工肛門","気管切開","妊　娠","感染症","喘　息","ｱﾚﾙｷﾞｰ","現在状況","30分静止","経口摂取","自力歩行"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"予約日時：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,null,null,null,"時",null,null,null,null,null,"分"]
[]
["貴医療機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療科\n\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当医師（フルネーム）\n\n"]
[]
["TEL:",null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（頭頂部から大腿基部まで）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※PET/CT装置の特性上、吸収補正は低線量CTで減弱補正を行います。 "]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"※複数部位選択可能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["受診結果DISK",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※ご不要の場合にはご連絡ください。"]
[]
[]
[]
["ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性　別",null,null,null,null,null,"住所",null,null,null,null,"〒",null,null,null,null,null,null,null,"―"]
["患者様名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様"]
[]
["生年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"TEL：",null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,"）",null,null,null,null,null,null,null,null,"携帯：",null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,"）"]
["臨床診断"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
["検査目的",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,"※スクリーニングおよび良悪鑑別は自費となります。"]
["持込画像",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,"※持込画像は、データ（DISK）のみお受けいたします。"]
["病理検査・\n腫瘍ﾏｰｶｰ・\n臨床経過等\n\n※必ずご記入\nください。"]
[]
[]
[]
[]
[]
[]
[]
["治 療 歴",null,null,null,null,null,null,null,null,null,"手術歴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,"術式",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"化学療法",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月",null,null,"術式",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"放射線治療",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,"月"]
["糖 尿 病",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"mg/dl）",null,null,null,null,null,null,"※糖尿病薬剤は検査当日の使用を避けてください。\n※空腹時血糖200mg/dlを超える場合はご相談ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"1ヶ月以内の\nG-CSFの使用"]
["ﾍﾟｰｽﾒｰｶｰ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"妊　娠",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"現在状況"]
["体内金属",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）",null,null,"感染症",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）",null,null,"30分静止"]
["人工肛門",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）",null,null,"喘　息",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"経口摂取",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）"]
["気管切開",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）",null,null,"ｱﾚﾙｷﾞｰ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）",null,null,"自力歩行",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※自立歩行できない方は不可"]
["本診療情報提供書をご利用される場合、ゆうあいクリニック台場での検査結果を直接依頼元の医療機関へ提供いたします。この取扱いについて受診者の\n同意がある場合に限り、本診療情報提供書をご利用ください。なお、特別な取扱いが必要な場合には、下記の電話番号へご連絡ください。"]
[]
["コールセンター臨床　FAX 045-548-1969 / TEL 045-540-8215"]
[]
["予約フリーダイヤル　0120-852-026",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D02_01_01_01_0001-8"]
[]
[]
["この欄は貴院IDのご記入・エンボス印字等にご利用ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜２枚目＞"]
[{"$f":"IF(ISBLANK(A2), \"\", A2)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ご紹介元医療機関宛"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療情報提供書（画像診断依頼書）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ゆうあいクリニック台場　片山　敦　先生"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"以下の患者様の画像診断をお願い申し上げます。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"予約日時：",null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(AX8), \"\", AX8)","v":""},null,null,null,null,null,null,null,"年",null,{"$f":"IF(ISBLANK(BH8), \"\", BH8)","v":""},null,null,null,"月",null,{"$f":"IF(ISBLANK(BN8), \"\", BN8)","v":""},null,null,null,"日（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,{"$f":"IF(ISBLANK(CJ8), \"\", CJ8)","v":""},null,null,null,"時",null,{"$f":"IF(ISBLANK(CP8), \"\", CP8)","v":""},null,null,null,"分"]
[]
["貴医療機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療科\n\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当医師（フルネーム）\n\n"]
[{"$f":"IF(ISBLANK(A11), \"\", A11)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(AH11), \"\", AH11)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(BO11), \"\", BO11)","v":""}]
["TEL:",null,null,null,null,{"$f":"IF(ISBLANK(F12), \"\", F12)","v":""},null,null,null,null,null,"（",null,null,{"$f":"IF(ISBLANK(O12), \"\", O12)","v":""},null,null,null,null,null,null,null,"）",null,{"$f":"IF(ISBLANK(Y12), \"\", Y12)","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（頭頂部から大腿基部まで）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※PET/CT装置の特性上、吸収補正は低線量CTで減弱補正を行います。 "]
[]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"※複数部位選択可能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(CC19), \"\", CC19)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["受診結果DISK",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※ご不要の場合にはご連絡ください。"]
[]
[]
[]
["ふりがな",null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(K26), \"\", K26)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性　別",null,null,null,null,null,"住所",null,null,null,null,"〒",null,{"$f":"IF(ISBLANK(BB26), \"\", BB26)","v":""},null,null,null,null,null,"―",null,{"$f":"IF(ISBLANK(BJ26), \"\", BJ26)","v":""}]
["患者様名",null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(K27), \"\", K27)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(AU27), \"\", AU27)","v":""}]
[]
["生年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(W30), \"\", W30)","v":""},null,null,null,null,null,null,null,null,"年",null,null,{"$f":"IF(ISBLANK(AI30), \"\", AI30)","v":""},null,null,"月",null,null,{"$f":"IF(ISBLANK(AO30), \"\", AO30)","v":""},null,null,"日",null,null,"TEL：",null,null,null,null,{"$f":"IF(ISBLANK(AZ30), \"\", AZ30)","v":""},null,null,null,null,"（",null,{"$f":"IF(ISBLANK(BG30), \"\", BG30)","v":""},null,null,null,null,null,null,"）",null,{"$f":"IF(ISBLANK(BP30), \"\", BP30)","v":""},null,null,null,null,null,null,"携帯：",null,null,null,null,{"$f":"IF(ISBLANK(CB30), \"\", CB30)","v":""},null,null,null,null,"（",null,{"$f":"IF(ISBLANK(CI30), \"\", CI30)","v":""},null,null,null,null,null,null,"）",null,{"$f":"IF(ISBLANK(CR30), \"\", CR30)","v":""}]
["臨床診断"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(BW34), \"\", BW34)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
["検査目的",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(AR36), \"\", AR36)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,"※スクリーニングおよび良悪鑑別は自費となります。"]
["持込画像",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(BR37), \"\", BR37)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,"※持込画像は、データ（DISK）のみお受けいたします。"]
["病理検査・\n腫瘍ﾏｰｶｰ・\n臨床経過等\n\n※必ずご記入\nください。",null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(K39), \"\", K39)","v":""}]
[]
[]
[]
[]
[]
[]
[]
["治 療 歴",null,null,null,null,null,null,null,null,null,"手術歴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(AB47), \"\", AB47)","v":""},null,null,null,null,null,"年",null,{"$f":"IF(ISBLANK(AJ47), \"\", AJ47)","v":""},null,null,"月",null,null,"術式",null,null,null,{"$f":"IF(ISBLANK(AT47), \"\", AT47)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"化学療法",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(CI47), \"\", CI47)","v":""},null,null,null,null,null,"年",null,{"$f":"IF(ISBLANK(CQ47), \"\", CQ47)","v":""},null,null,"月"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(AB48), \"\", AB48)","v":""},null,null,null,null,null,"年",null,{"$f":"IF(ISBLANK(AJ48), \"\", AJ48)","v":""},null,null,"月",null,null,"術式",null,null,null,{"$f":"IF(ISBLANK(AT48), \"\", AT48)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"放射線治療",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(CI48), \"\", CI48)","v":""},null,null,null,null,null,"年",null,{"$f":"IF(ISBLANK(CQ48), \"\", CQ48)","v":""},null,null,"月"]
["糖 尿 病",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(W49), \"\", W49)","v":""},null,null,null,null,null,null,null,"mg/dl）",null,null,null,null,null,null,"※糖尿病薬剤は検査当日の使用を避けてください。\n※空腹時血糖200mg/dlを超える場合はご相談ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"1ヶ月以内の\nG-CSFの使用"]
["ﾍﾟｰｽﾒｰｶｰ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"妊　娠",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"現在状況"]
["体内金属",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(W51), \"\", W51)","v":""},null,null,null,null,null,null,null,"）",null,null,"感染症",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(BA51), \"\", BA51)","v":""},null,null,null,null,null,null,null,"）",null,null,"30分静止"]
["人工肛門",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(W52), \"\", W52)","v":""},null,null,null,null,null,null,null,"）",null,null,"喘　息",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"経口摂取",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(CM52), \"\", CM52)","v":""},null,null,null,null,null,null,null,"）"]
["気管切開",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(W53), \"\", W53)","v":""},null,null,null,null,null,null,null,"）",null,null,"ｱﾚﾙｷﾞｰ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(BA53), \"\", BA53)","v":""},null,null,null,null,null,null,null,"）",null,null,"自力歩行",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※自立歩行できない方は不可"]
["本診療情報提供書をご利用される場合、ゆうあいクリニック台場での検査結果を直接依頼元の医療機関へ提供いたします。この取扱いについて受診者の\n同意がある場合に限り、本診療情報提供書をご利用ください。なお、特別な取扱いが必要な場合には、下記の電話番号へご連絡ください。"]
[]
["コールセンター臨床　FAX 045-548-1969 / TEL 045-540-8215"]
[]
["予約フリーダイヤル　0120-852-026",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D02_01_01_01_0001-8"]
[]
[]
["この欄は貴院IDのご記入・エンボス印字等にご利用ください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜３枚目＞"]
[{"$f":"IF(ISBLANK(A2), \"\", A2)","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査予約票"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"予約日時：",null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(AX8), \"\", AX8)","v":""},null,null,null,null,null,null,null,"年",null,{"$f":"IF(ISBLANK(BH8), \"\", BH8)","v":""},null,null,null,"月",null,{"$f":"IF(ISBLANK(BN8), \"\", BN8)","v":""},null,null,null,"日（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,{"$f":"IF(ISBLANK(CJ8), \"\", CJ8)","v":""},null,null,null,"時",null,{"$f":"IF(ISBLANK(CP8), \"\", CP8)","v":""},null,null,null,"分"]
[]
["貴医療機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療科\n\n",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当医師（フルネーム）\n\n"]
[{"$f":"IF(ISBLANK(A11), \"\", A11)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(AH11), \"\", AH11)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(BO11), \"\", BO11)","v":""}]
["TEL:",null,null,null,null,{"$f":"IF(ISBLANK(F12), \"\", F12)","v":""},null,null,null,null,null,"（",null,null,{"$f":"IF(ISBLANK(O12), \"\", O12)","v":""},null,null,null,null,null,null,null,"）",null,{"$f":"IF(ISBLANK(Y12), \"\", Y12)","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（頭頂部から大腿基部まで）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," "]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"※複数部位選択可能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（",null,{"$f":"IF(ISBLANK(CC19), \"\", CC19)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
["受診結果DISK",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※ご不要の場合にはご連絡ください。"]
[]
[]
[]
["ふりがな",null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(K26), \"\", K26)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性　別",null,null,null,null,null,"住所",null,null,null,null,"〒",null,{"$f":"IF(ISBLANK(BB26), \"\", BB26)","v":""},null,null,null,null,null,"―",null,{"$f":"IF(ISBLANK(BJ26), \"\", BJ26)","v":""}]
["患者様名",null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(K27), \"\", K27)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(AU27), \"\", AU27)","v":""}]
[]
["生年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(ISBLANK(W30), \"\", W30)","v":""},null,null,null,null,null,null,null,null,"年",null,null,{"$f":"IF(ISBLANK(AI30), \"\", AI30)","v":""},null,null,"月",null,null,{"$f":"IF(ISBLANK(AO30), \"\", AO30)","v":""},null,null,"日",null,null,"TEL：",null,null,null,null,{"$f":"IF(ISBLANK(AZ30), \"\", AZ30)","v":""},null,null,null,null,"（",null,{"$f":"IF(ISBLANK(BG30), \"\", BG30)","v":""},null,null,null,null,null,null,"）",null,{"$f":"IF(ISBLANK(BP30), \"\", BP30)","v":""},null,null,null,null,null,null,"携帯：",null,null,null,null,{"$f":"IF(ISBLANK(CB30), \"\", CB30)","v":""},null,null,null,null,"（",null,{"$f":"IF(ISBLANK(CI30), \"\", CI30)","v":""},null,null,null,null,null,null,"）",null,{"$f":"IF(ISBLANK(CR30), \"\", CR30)","v":""}]
[]
["■検査当日にお持ちいただくもの",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"■アクセス"]
[]
[" 健康保険証、各種受給者証\n （老人医療受給者証など）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 問診票・検査同意書\n（検査当日までにご記入ください）"]
[" 主治医からお預かりになった診療情報\n 提供書（紹介状）、ＣＴやＭＲＩなど\n のフィルム（DISK）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 検査料金"]
[]
["■検査にあたってのご注意"]
[]
["　検査の診断精度を維持するため、以下の事項を順守してください。\n　・ご来院の5時間前以降はお食事をとらないでください（水・無糖のお茶は可）\n　・下剤は検査前日から、糖尿病薬は検査当日から控えてください。\n　・検査前日から検査終了後まで激しい運動はお避けください。"]
["　予約時刻の10分前にはご来院ください。予定時刻に間に合わない場合やご来院でき\nない場合は、判明した時点で直ちにご連絡ください。検査時間は約3時間を予定してお\nりますが、前後することもございます。"]
["　本診療情報提供書をご利用いただいて検査をお受けになる場合は、検査結果を直接依\n頼元医療機関の主治医に通知いたします。当クリニックでは検査結果についての説明は\n行いません。主治医からのご説明をお受けください。なお、この取扱いに同意いただけ\nる場合に限り、検査をお受けください。"]
["　通常PET検査は1回の撮影で終了しますが、撮影部位や生理的な集積の仕方によって、十分な情報が得られない場\n合があります。このような場合、放射線科医の判断で引き続き2回目の撮影をお願いする場合があります。これは遅\n延撮影法Delayed Scanといわれる方法で、PETの診断精度をさらに高めることができます。なお2回目の撮影を\n行っても被ばく量、検査料金ともに増えることはありません。\n（ご注意）・2回目の撮影を行った場合、終了時間が1時間ほど延長となります。\n　　　　　・撮影回数と診断するご病気の程度とは関係ありません。"]
["　　　　　　"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"D02_01_01_01_0001-8"]