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{"sheet":"MRI検査申込書","index":0,"n_rows":50,"n_cols":48,"rows_kept":50,"cut":false,"hidden":false,"merged":[[49,1,49,41],[35,36,35,37],[40,36,40,37],[37,36,37,37],[46,1,47,6],[47,22,47,41],[48,1,48,41],[43,1,43,4],[44,1,44,4],[43,6,43,8],[44,6,44,8],[43,11,43,13],[44,9,44,10],[44,33,44,39],[44,11,44,13],[43,14,44,20],[13,1,13,8],[13,9,13,41],[16,16,16,19],[21,16,21,19],[22,16,22,19],[16,1,16,4],[17,30,17,33],[24,1,24,4],[29,1,29,4],[35,10,35,12],[16,30,16,33],[0,1,0,41],[8,4,8,19],[8,20,8,22],[9,20,10,22],[11,4,11,22],[8,23,10,26],[9,1,10,3],[11,1,11,3],[8,1,8,3],[9,4,10,19],[15,1,15,41],[4,1,5,20],[3,22,3,39],[4,28,5,39],[43,36,43,37],[43,40,43,41],[43,9,43,10],[7,15,7,41],[11,23,11,26],[9,27,10,41],[11,27,11,41],[8,27,8,31],[8,32,8,39],[35,15,35,18],[41,36,41,37],[42,36,42,37],[35,40,35,41],[36,40,36,41],[33,1,33,40],[42,40,42,41],[36,36,36,37],[38,36,38,37],[39,36,39,37],[37,40,37,41],[38,40,38,41],[39,40,39,41],[40,40,40,41],[41,40,41,41]]}
[null,"MRI検査申込書（兼　検査終了報告書）"]
[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,"石井整形外科"]
[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,"内山整形外科医院"]
[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,"恩田クリニック"]
[null,"Ingenia 1.5T OMEGA HP　株式会社フィリップス・ジャパン",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,"大正",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,"昭和",null,null,null,"国保北条診療所"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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,null,null,"関病院"]
[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,"令和",null,null,null,"つよしクリニック"]
[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,"男","樋口内科医院扇町"]
[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,"女","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,"検査予約日時",null,null,null,null,null,null,null,"　　　　　　　　年　　　　　　月　　　　　　日（　　　　　曜日）　　　　　　　時　　　　　　　分              "]
[]
[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）MRIシーケンス別紙ご覧ください"]
[null,"頭頚部",null,null,null,null,"脳ﾙｰﾁﾝ急性期",null,null,null,null,null,null,null,null,null,"椎　体",null,null,null,null,"頚椎・頸髄",null,null,null,null,null,null,null,null,"骨　盤",null,null,null,null,"右股関節",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"脳ﾙｰﾁﾝ+NeckA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"胸椎",null,null,null,null,null,null,null,null,"股関節",null,null,null,null,"左股関節",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"脳ﾙｰﾁﾝ+3D",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"腰椎",null,null,null,null,null,null,null,null,null,null,null,null,null,"両股関節",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"脳ﾙｰﾁﾝ+VSRAD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"胸腰髄",null,null,null,null,null,null,null,null,null,null,null,null,null,"骨盤部",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"脳ﾙｰﾁﾝ+脳幹薄層",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"胸腰椎移行部",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,"視神経",null,null,null,null,null,null,null,null,null,"胸　部",null,null,null,null,"胸部",null,null,null,null,null,null,null,null,null,null,null,null,null,"腹部",null,null,null,null,null,null,null,false,false,false]
["  ",null,null,null,null,null,"副鼻腔",null,null,null,null,null,null,null,null,null,"腹　部",null,null,null,null,"MRCP",null,null,null,null,null,null,null,null,null,null,null,null,null,"肝臓",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"頚部",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,null,null,false]
[null,"上　肢",null,null,null,null,"右肩関節",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右肘関節",null,null,null,null,null,null,null,null,null,null,null,null,null,"右手関節",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"左肩関節",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左肘関節",null,null,null,null,null,null,null,null,null,null,null,null,null,"左手関節",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"右上腕骨",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右前腕骨",null,null,null,null,null,null,null,null,null,null,null,null,null,"右手関節",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"左上腕骨",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左前腕骨",null,null,null,null,null,null,null,null,null,null,null,null,null,"その他",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"右手",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左手",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false]
[null,"下　肢",null,null,null,null,"右大腿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右下腿骨",null,null,null,null,null,null,null,null,null,null,null,null,null,"右足",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"左大腿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左下腿骨",null,null,null,null,null,null,null,null,null,null,null,null,null,"左足",null,null,null,null,null,null,null,false,false,false]
[null,null,null,null,null,null,"右膝関節",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"右足関節",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,"左膝関節",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"左足関節",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,false,false]
[null,"追加の検査希望"]
[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,"★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,"体重",null,null,"（",null,null,null,null,null,"）","Kg",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,null,"あり",null,null,null,"なし",null,null,null,null,null,"未検査"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"人工内耳",null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし",null,null,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,"脳動脈ｸﾘｯﾌﾟ･外科的ｸﾘｯﾌﾟ",null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし",null,null,null,null,null,"Hbs抗原"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"整形外科的金属（人工関節等）",null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし",null,null,null,null,null,"Hbe抗原"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"義歯（ﾏｸﾞﾈｯﾄ式義歯）義眼",null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし",null,null,null,null,null,"HCV抗体"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"刺青(ﾀﾄｩｰ)",null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし",null,null,null,null,null,"HIV"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ﾉﾙｽﾊﾟﾝﾃｰﾌﾟ･ﾆｭｰﾌﾟﾛﾊﾟｯﾁ",null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし",null,null,null,null,null,"MRSA"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"閉所恐怖症",null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし",null,null,null,null,null,"その他耐性菌"]
[null,"読影希望",null,null,null,null,"あり",null,null,null,null,"なし",null,null,"読影結果は日郵送致　　　になります",null,null,null,null,null,null,null,null,"長時間の静止の可否",null,null,null,null,null,null,null,null,null,null,null,null,"可",null,null,null,"否",null,null,false,false]
[null,"至急読影",null,null,null,null,"あり",null,null,null,null,"なし",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,false,false]
[]
[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。"]