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{"sheet":"申込 保険情報","index":0,"n_rows":36,"n_cols":25,"rows_kept":36,"cut":false,"hidden":false,"merged":[[29,1,29,5],[22,1,22,2],[22,3,23,4],[22,5,23,9],[22,10,23,22],[23,1,23,2],[24,1,24,2],[25,3,25,6],[25,7,25,12],[25,13,25,22],[26,1,26,2],[28,1,28,5],[17,1,17,2],[17,24,18,24],[19,24,21,24],[20,1,20,2],[20,3,20,5],[21,1,21,2],[1,0,1,24],[4,2,4,11],[5,2,5,11],[10,3,10,9],[10,10,10,11],[10,12,11,13],[10,24,14,24],[11,1,12,2],[11,3,12,9],[11,10,12,11],[12,12,14,13],[13,1,14,2]]}
[]
["検査等申込 兼 保険情報送信様式（ＦＡＸ用）"]
[]
[null,null,"紹介先",null,null,null,null,null,null,null,null,null,null,"紹介元"]
[null,null,"医療法人社団相和会　渕野辺総合病院",null,null,null,null,null,null,null,null,null,null,"医療機関名"]
[null,null,"メディカルサポートセンター\n　地域医療連携課 医療連携係",null,null,null,null,null,null,null,null,null,null,"医師名"]
[null,null,"TEL","０４２－７５４－３３０２（直通）",null,null,null,null,null,null,null,null,null,"TEL"]
[null,null,"FAX","０４２－７５４－３３２３（直通）",null,null,null,null,null,null,null,null,null,"FAX"]
[]
[null,"※太枠内をご記入ください。項目・必要個所は、マル　　　または ☑をお願いいたします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□開放登録医"]
[null,"フリガナ",null,null,null,null,null,null,null,null,"性別",null,"ＴＥＬ",null,null,null,null,null,null,null,null,null,"連絡の取れる電話番号をお願いいたします",null,"渕野辺総合病院\n記入欄"]
[null,"患者氏名",null,"様",null,null,null,null,null,null,"男・女"]
[null,null,null,null,null,null,null,null,null,null,null,null,"住所",null,"〒"]
[null,"生年月日",null,"大","昭","平","令"]
[null,null,null,null,"年",null,"月",null,"日",null,null,"歳"]
[null,"渕野辺総合病院受診歴　 　有　 ・ 　無　　  診察券番号（　　　　　　　　　　　　　　　）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受付日"]
[null,"傷病名",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,"※記入せず、診療情報提供書のFAXでも結構です"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"予約内容確認者\n(連携室)"]
[null,"　 予約\n\n項目",null,"予約日時：",null,null,null,null,"月",null,null,"日","（",null,"）",null,null,"時",null,null,"分"]
[null,"診察",null,"診療科",null,null,null,null,null,"科","予約医師"]
[null,"ＣＴ",null,"単純\n・\n造影",null,null,null,null,null,null,"\n造影の場合　検査日（　　　/　　　）\n\neGFR > 　　　　　　又は（Cr：　　　　㎎/dl）\n\n※アレルギー対応や撮影方法等、遠慮なくお問い合わせください\n\n"]
[null,"ⅯＲI"]
[null,"エコー",null,"撮影部位",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"内視鏡医\n確認印"]
[null,"胃カメラ",null,"経鼻 ・ 経口",null,null,null,"適応があった場合の尿素呼気試験\n実施可  ・  不可",null,null,null,null,null,"※組織検査をした場合は結果郵送までに、2週間程お時間をいただきます。検査所見のみ先行FAXも可能ですので、ご所望ください。",null,null,null,null,null,null,null,null,null,null,"依頼"]
[null,"その他",null,"マンモグラフィー　・　骨塩定量　・　栄養指導　・　（　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"結果"]
[]
[null,"画像のご希望媒体",null,null,null,null,"　フィルム　・　ＣＤ-Ｒ　・　プリント　・　画像不要(レポートのみ）"]
[null,"ＣＴ/ⅯＲI 特記指示",null,null,null,null,"□当日、画像の患者手渡しを希望",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※特記指示がない場合は後日郵送いたします"]
[]
[null,"　・当日の持ちもの"]
[null,null,"診療情報提供書、健康保険証、診察券(お持ちの方)、検査に必要な書類（同意書、問診票）、お薬手帳"]
[null,"　・ご不明点は、地域医療連携課へお問い合わせください。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2025年6月　改訂"]

{"sheet":"MRI検査予約票","index":1,"n_rows":38,"n_cols":11,"rows_kept":38,"cut":false,"hidden":false,"merged":[[34,7,34,10],[35,7,35,10],[36,7,36,10],[24,1,24,9],[25,1,25,10],[26,1,26,9],[27,1,27,10],[28,1,28,9],[33,7,33,10],[17,1,19,4],[17,5,18,7],[17,8,18,10],[19,5,19,10],[20,1,22,4],[20,5,21,7],[20,8,21,10],[22,5,22,10],[14,1,16,4],[14,5,15,7],[14,8,15,10],[16,5,16,10],[1,1,2,2],[1,3,2,6],[1,7,2,7],[3,1,3,2],[3,3,3,6],[4,1,6,2],[4,3,5,7],[4,8,5,10],[6,3,6,10],[13,1,13,4],[13,5,13,7],[13,8,13,10]]}
[null,"ＭＲＩ検査予約票"]
[null,"フリガナ",null,null,null,null,null,"性 別"," 生年月日"]
[null,null,null,null,null,null,null,null,"　大　 　昭　 　平　 　令"]
[null,"氏  名",null,null,null,null,null,"男　・　女","年","月　","日　"]
[null,"予約日時",null,"  　　　年　 　　　月　 　　　日  （　　　 　）",null,null,null,null,"時　　　　　　分"]
[]
[null,null,null,"※予約時間の20分前までに受付をして、1階の放射線科受付へお越し下さい"]
[null,null,null,"予約時間が過ぎてしまうと検査の順番が変更、または当日検査が出来ない場合があります。"]
[]
[null,"◎","注意事項　　　※ 「MRI検査を受けられる方へ」もよくお読みください"]
[null,"・MRI検査室は、強い磁場となっています。"]
[null,"　検査着に着替え、磁気カードや金属類などは全てロッカーへ入れていただきます。"]
[]
[null,"検査",null,null,null,"食べ物",null,null,"飲み物"]
[null,"造影なしの検査\n※子宮・卵巣・腹部以外",null,null,null,"制限はありません",null,null,"制限はありません"]
[]
[null,null,null,null,null,"内服薬の制限はありません"]
[null,"MRCP",null,null,null,"検査の4時間前まで\nに済ませてください",null,null,"検査の4時間前まで飲めます"]
[]
[null,null,null,null,null,"内服薬の服用は主治医にご相談ください"]
[null,"造影検査  または\n子宮・卵巣・腹部検査\n※MRCP以外",null,null,null,"検査の4時間前まで\nに済ませてください",null,null,"乳製品を含まない水・お茶に\n限り積極的にお飲みください"]
[]
[null,null,null,null,null,"内服薬の服用は主治医にご相談ください"]
[]
[null,"・検査所要時間は、撮影部位により、10分～60分と異なります。"]
[null,"・ウイルス性感染症、水痘・帯状疱疹等の皮膚疾患の診断を受けた場合は事前に渕野辺総"]
[null,"　合病院放射線室までご連絡ください。"]
[null,"・救急、重症患者さんの対応などにより検査開始時間が前後する場合がありますのでご了承"]
[null,"　ください。"]
[null,"・ご予約の変更は、紹介元の医療機関へご連絡ください。"]
[]
[]
[]
[null,null,null,null,null,null,null,"医療法人社団　相和会　渕野辺総合病院"]
[null,null,null,null,null,null,null,"〒252-0206　相模原市中央区淵野辺3-2-8"]
[null,null,null,null,null,null,null,"ＴＥＬ 042-754-2222（代）"]
[]
[null,null,null,null,null,null,null,null,null,null,"2025年6月　改訂"]

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[null,null,null,null,null,null,null,null,null,null,null,null,"地域連携用MRI安全確認リスト\n　（事前問診票）"]
["　　　 "]
[]
[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,"&TagXrayStartDate&"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"患者氏名：",null,null,null,null,null,null,null,null,"    （男 ・ 女）",null,null,null,null,{"$f":"IF(TRIM(AB4)<>\"\",AB4,TEXT(TODAY(),\"YYYY/MM/DD\"))","v":"&TagXrayStartDate&"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"MID(AB5,1,4)","v":"&Tag"}]
["医療機関名：",null,null,null,null,null,null,null,null,null,null,null,null,"生年月日： T・S・H・R",null,null,null,null,"  　       　年　　　　 　　月　　　　 　　日",null,null,null,null,null,null,null,null,{"$f":"MID(AB5,6,2)","v":"ra"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"MID(AB5,9,2)","v":"St"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"検査予約日：",null,null,"　　　  　　年　　　　　月　　　　　日　　（　　　）",null,null,null,null,null,null,null,null,null,null,"&TagXrayStartTime&"]
["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,"&tagPatAge&"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"予約時間：",null,null,"　　　　　時　　　　　　分",null,null,null,null,"　（20分前に来院）",null,null,null,null,null,{"$f":"LEFT(AB10,FIND(\"歳\",AB10))","v":{"$error":"#VALUE!"}}]
["★　絶対禁忌",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"ASC(#REF!)","v":{"$error":"#REF!"}}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"DATEVALUE(AB12)","v":{"$error":"#REF!"}}]
["①","除細動器・ペースメーカー装着",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり",null,null,null,"※撮像できません"]
["②","人工内耳",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["③","眼球内金属粉混入（職業・事故等）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["④","生命維持に必要な金属、電子機器モニター類を外せないもの",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑤","広範囲ないれずみ",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
[]
["★　撮像に注意が必要　　",null,null,null,null,null,null,null,null,"☆　☆　手術後、8週間以内は確認が必要　☆　☆"]
[]
["①","脳室腹腔シャント（調整式）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり",null,null,null,"手術内容、年月、施設名"]
["②","人工弁・脳動脈瘤クリップ・ステント　　",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["③","体内金属",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["④","手術歴",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり",null,null,null,"　　　　        　　　　　　"]
["⑤","白内障手術(左・右）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑥","消化器内視鏡クリップ(留置後2週間以内)",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑦","体内結さつ用クリップ（腹腔鏡下胆嚢摘出術 等）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑧","歯科インプラント",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
[]
["⑨","体内人工物（金属製の避妊リング）の使用",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑩","心臓病・禁煙薬の貼布薬（ニトロダームＴＴＳ、ニコチネルＴＴＳ）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑪","経皮吸収型製剤（貼布薬）　（薬剤名　　　　　　　　　　　　　　 　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑫","インスリンポンプ・持続グルコース測定器（FreeStyle リブレ 等）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑬","いれずみ　(部位と範囲： 　　　　　　　　　　　　　　　　　　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑭","義眼（取り外し可能な物）、コンタクト・カラーコンタクト",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑮","閉所恐怖症",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑯","てんかんと言われた事は有りますか",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑰","不整脈",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり",null,null,null,"＊ＭＲＩ検査が可能かどうか施行医に確認が必要です\n体内インプラントがある場合、別用紙が必要となりますので正確な記入をお願いします"]
["⑱","増毛スプレー、毛髪着色料(部分白髪染め) 　→　一時的なもの",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑲","アートメイク（アイライン、つけまつげ、マスカラ、アイシャドーなど）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["⑳","入れ歯・かつら・ウィッグ・ヘアエクステンション（つけ毛）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["㉑","ネイルアート、ジェルネイル、つけ爪、アクリルネイル、マニキュア、ＵＶケア用品",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["㉒","装具・コルセット・ストーマベルトなど",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり"]
["㉓","尿道留置カテーテル　（磁石式開閉キャップは交換が必要）",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり",null,null,null,null,null,null,null,null,null,null,null,"ＩＤ(10桁)"]
["㉔","妊娠の可能性　　（　　　　　　）ヶ月　　・　（　　　　）週",null,null,null,null,null,null,null,null,null,null,null,null,null,"なし・あり",null,null,null,null,null,null,null,null,null,null,null,"書類コード(5桁)"]
["㉕","最終MRI検査歴　　なし　／　当院　／　他施設　 ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"科コード(3桁)"]
[null,"最終検査歴が他施設の場合は、　　　　　　　　　　　右記項目の記入をお願いします",null,null,null,null,null,null,null,null,"施設名（　　　　　　　　　　　　　）　（西暦　　　　　　年　　　月）　部位（　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"作成者ID(8桁)"]
[null,null,null,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(2桁)"]
[null,"事前問診確認者　　　　　　　　当日確認技師　　　　　　　　＊",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"月(2桁)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"日(2桁)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"時(2桁)"]
[null,{"$f":"IF(LEN(Q58)=40,Q58,\"\")","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,"分(2桁)"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"2024年12月　改訂　　MRI室(内線2114)",null,null,null,null,null,null,null,null,null,null,"秒(2桁)"]
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["MRI検査を受けられる方へ"]
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[]
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["●注意事項（よくお読みください）"]
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["＊金属製または磁気に敏感な物品・素材が分からないものを持っていたり、身につけ、そのままＭＲ検査室に入室すると、吸着や熱傷（やけど）事故につながり大変危険です。金属類・化粧品等で不明な場合は、それぞれの商品の製造元にお問い合わせください。また、申告していない手術歴があった・検査日前までに手術を受けた場合は確認が必要となりますので、当院までご連絡ください。確認が出来ない場合は、放射線科の判断で場合により検査の変更をお願いすることがあります。下記の内容を必ず確認してください。\n"]
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[null,null,"毛髪着色料（一時染毛料、部分白髪染めなど） \n［マスカラタイプ/パウダータイプ/マーカータイプ/エアゾールタープ]\n増毛スプレー",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査前日に洗髪をして洗い流し、当日は使用しないで下さい"]
[]
[]
[null,null,"アートメイク、つけまつ毛、エクステ"]
[]
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[null,null,null,null,"ネイルアート、ジェルネイル、つけ爪\nアクリルネイル、手足のマニキュア"]
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[null,null,"保温下着（ヒートテックなど）貼り薬、塗り薬、軟膏類、テープ類、制汗剤　　　　　　　　　"]
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[null,null,"＊インスリンポンプ、グルコースモニター(リブレ)"]
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[]
[]
[]
[]
[" □ 心臓病・禁煙薬の貼布薬（ニトロダームＴＴＳ、ニコチネルＴＴＳ）⇒予備をお持ちください"]
[" □ 経皮吸収型製剤（貼布薬）　（薬剤名　　　　　　　　　　　　　　　　　）　"]
[null,null,"*検査時に剥がせるか主治医に確認が必要です"]
[" □ コンタクト・カラーコンタクト、ファッションレンズ、眼鏡⇒ケースをお持ちください"]
[" □ アクセサリー類、腕時計など"]
[" □ 化粧（ＵＶケア用品）"]
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[]
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[" □紹介状　□健康保険証　□診察券（お持ちの方）　□お薬手帳"]
[" □検査予約票",null,null,null,null," □ MRI安全確認リスト（当日持参する方のみ）"]
[" □体内の金属・医療機器の詳細が分かる資料（カード・手帳等お持ちの方）"]
[" □造影検査 説明・同意書（造影検査の方）"]
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[null,null,null,"お問い合わせ先　　渕野辺総合病院　042-754-2222（代）　　MRI室（内線2114）"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"地域連携用　2025年6月　改訂"]