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[null,"CT検査申込書（兼　検査終了報告書）"]
[]
[null,"申込先医療機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査依頼元医療機関名",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,"石井整形外科"]
[null,"独立行政法人 国立病院機構　新潟病院",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"内山整形外科医院"]
[null,"Aquilion Prime SP キャノンメディカルシステムズ株式会社",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"依頼元医師名",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,"恩田クリニック"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"柏崎厚生病院"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"国保北条診療所"]
[null,"患者様基本情報",null,null,null,null,null,null,null,null,null,null,null,null,null,"（新潟病院患者ＩＤ ：　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"男","関病院"]
[null,"ﾌﾘｶﾞﾅ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",null,null,"生年　　　　月日",null,null,null,"年号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女","つよしクリニック"]
[null,"氏名",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,"年        月    　  日 (　   　   歳)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"樋口内科医院扇町"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正","横田整形外科医院"]
[null,"住所",null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話",null,null,null,"  (              )      　  -",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"昭和"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"平成"]
[null,"検査予約日時",null,null,null,null,null,null,null,"　　　　　　　　年　　　　　　月　　　　　　日（　　　　　曜日）　　　　　　　時　　　　　　　分              ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和"]
[]
[null,"●希望検査項目（希望する項目にチェックをつけてください）"]
[null,"頭頚部",null,null,null,null,null,null,"頭部",null,null,null,null,null,null,null,"胸　部",null,null,null,null,null,null,"胸部",null,null,null,null,null,null,"腹　部",null,null,null,null,null,null,"腹部－骨盤",null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,null,null,"頭部－骨盤",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"胸腹部",null,null,null,null,null,null,null,null,null,null,null,null,null,"腹部－骨盤",null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,null,null,"頚部",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"胸部－骨盤",null,null,null,null,null,null,null,null,null,null,null,null,null,"骨盤腔",null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,null,null,"頚胸部",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false]
[null,null,null,null,null,null,null,null,"頚部－骨盤",null,null,null,null,null,null,null,"椎　体",null,null,null,null,null,null,"頚椎",null,null,null,null,null,null,"上　肢",null,null,null,null,null,null,"上肢",null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,null,null,"眼窩",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"胸椎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false]
[null,null,null,null,null,null,null,null,"副鼻腔",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"腰椎",null,null,null,null,null,null,"下　肢",null,null,null,null,null,null,"下肢",null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"仙尾椎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"全脊椎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,"関　節",null,null,null,null,null,null,"右",null,"（",null,null,null,null,null,null,null,"）",null,"関節",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[null,null,null,null,null,null,null,null,"左",null,"（",null,null,null,null,null,null,null,"）",null,"関節",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false]
[]
[null,"臨床診断･検査目的等（大きくはっきりと記載願います）"]
[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,"体重（　　　　）kg"]
[]
[]
[]
[]
[null,"読影希望",null,null,null,null,null,"あり",null,null,null,null,"なし",null,null,null,null,"至急読影",null,null,null,null,null,"あり",null,null,null,null,"なし"]
[null,"依頼された場合は読影後結果を後日郵送致します"]
[]
[null,"★患者様に関する事前ﾁｪｯｸ表（該当する方にﾁｪｯｸ）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"心臓ﾍﾟｰｽﾒｰｶｰ・人工弁",null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"妊娠中又は妊娠可能性",null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし"]
[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,"あり",null,null,null,"なし"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"感染症",null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,"検査終了報告　　※新潟病院記載欄",null,null,null,null,null,"※上記にかかる検査を実施致しました。実施年月日：　　　　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,"NHO新潟病院地域医療連携相談室"]
[null,"＊画像CD-Rは当院での検査後、患者様にお渡し致します。（場合によっては後日貴院宛てに郵送致します）"]
[null,"＊造影剤使用による撮影をご希望の場合は当院での診察が必要となります。受診手続きをしてください。"]