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{"sheet":"超音波エコー検査申込書","index":0,"n_rows":41,"n_cols":44,"rows_kept":41,"cut":false,"hidden":false,"merged":[[0,1,0,40],[4,1,5,20],[7,15,7,40],[8,1,8,3],[8,4,8,19],[8,20,8,22],[8,23,10,26],[9,1,10,3],[9,4,10,19],[9,20,10,22],[9,27,10,40],[8,27,8,29],[8,30,8,38],[3,22,3,37],[4,27,5,39],[11,1,11,3],[11,4,11,22],[11,23,11,26],[11,27,11,40],[38,1,39,6],[39,22,39,40],[18,3,19,4],[24,2,24,39],[25,2,33,39],[34,2,34,7],[34,8,34,40],[35,8,35,40],[36,8,36,40],[40,1,40,40],[16,2,16,28],[13,1,13,8],[13,9,13,40],[18,30,19,37],[21,3,22,4],[21,5,22,14],[21,15,22,16],[21,17,22,36],[21,37,22,38],[18,18,19,19],[18,20,19,26],[18,28,19,29],[18,5,19,8],[18,10,19,11],[18,12,19,16]]}
[null,"超音波検査申込書（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,"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,"石井整形外科"]
[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,"内山整形外科医院"]
[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,"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,"柏崎厚生病院"]
[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,"大正","国保北条診療所"]
[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,"昭和","関病院"]
[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,"平成","つよしクリニック"]
[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,"令和","樋口内科医院扇町"]
[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,"男","横田整形外科医院"]
[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,"女"]
[null,"検査予約日時",null,null,null,null,null,null,null,"　　　　　　　　年　　　　　　月　　　　　　日（　　　　　曜日）　　　　　　　時　　　　　　　分              "]
[]
[]
[null,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,null,null,null,null,null,null,null,null,null,null,null,"■"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□"]
[null,null,null,"□",null,"心臓",null,null,null,null,"□",null,"頚動脈",null,null,null,null,null,"□",null,"下肢静脈",null,null,null,null,null,null,null,"□",null,"下肢動脈"]
[]
[]
[null,null,null,"□",null,"その他の超音波",null,null,null,null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[null,null,"臨床診断・検査目的など（大きくはっきりとご記入お願いいたします）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,"＊注意事項＊",null,null,null,null,null,"1検査部位がでやすい服装で来院してください"]
[null,null,null,null,null,null,null,null,"2腹部超音波検査を受けられる方で午前の予約の方は朝食禁・午後の予約の方は昼食禁"]
[null,null,null,null,null,null,null,null,"3その他の超音波検査については食事の制限はありません"]
[]
[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,"＊超音波検査の結果は全て、後日貴院宛てに郵送いたします。"]