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["RI検査申込書（兼　検査終了報告書）"]
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[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,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,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,null,null,null,null,"内山整形外科医院"]
[null,"Symbia Intevo2　シーメンスヘルスケア株式会社",null,null,null,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,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,null,null,null,"大正","柏崎厚生病院"]
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[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,null,null,null,null,"平成","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,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,null,"令和","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,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,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,null,null,null,null,"男","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,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,null,null,"女"]
[null,"身長",null,null,null,null,null,null,null,null,null,"cm",null,null,"体重",null,null,null,null,null,null,null,null,null,"kg"]
[]
[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）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"●その他依頼項目"]
[null,"①脳血流シンチ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"IMP",null,null,null,null,null,null,"⑥読　　影　　　　　要　　　　不要"]
[null,"②心臓交感神経機能",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MIBG"]
[null,"③骨シンチ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"MDP"]
[null,"④ドパミントランスポーターシンチ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FP-CIT"]
[null,"⑤その他（　　　　　　　　　　　　　　　　　　　　　　　）"]
[null,"【臨床診断・主訴・検査目的など】"]
[]
[]
[]
[]
[]
[]
[]
[null,null,"●","検査終了報告欄（実施内容報告）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"新潟病院　→　依頼元医療機関"]
[null,null,"（１）　使用アイソトープ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（２）ﾏﾙﾁｽﾗｲｽＣＴ",null,null,null,null,null,"（３）　画像媒体",null,null,null,null,null,null,null,null,"（４）　読影"]
[null,null,1,null,"パーヒューザミン注　222MBｑ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,1,null,"有",null,null,null,1,null,"ＣＤ保存",null,null,null,null,null,null,1,null,"有"]
[null,null,2,null,"ニューロライト注射液第一　600MBｑ"]
[null,null,3,null,"ミオＭＩＢＧ-Ｉ１２３注射液　111MBｑ"]
[null,null,4,null,"ベンゾダイン注　222MBｑ"]
[null,null,5,null,"テクネＭＤＰ注射液　740MBｑ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,null,"無",null,null,null,null,null,null,null,null,null,null,null,"枚",2,null,"無"]
[null,null,6,null,"クエン酸ガリウム（６７Ｇａ）注 148MBｑ"]
[null,null,7,null,"テクネシンチ注　１０Ｍ　370ＭＢｑ"]
[null,null,null,null,"テクネＭＡＡキット　1回分"]
[null,null,8,null,"ダットスキャン静注　167MBq"]
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