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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"]

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[]
[null,"上部消化管内視鏡検査（経鼻）\n内視鏡検査説明票",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【受付方法】\n  検査の20分前に総合受付で受付をして、東棟2階内視鏡・生理検査受付へお越しください\n【当日の持ちもの】\n  紹介状、健康保険証、診察券(お持ちの方）、内視鏡同意書・問診票、お薬手帳や薬の説明書"]
[]
[]
[]
[]
[null,null,"検査日の変更は、ご紹介元へお願いいたします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"MID(BI6,1,4)","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"MID(BI6,6,2)","v":""}]
[null,"日付",null,"検査前日",null,null,null,null,null,null,null,null,null,null,null,null,null,"検査当日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,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(BI6,9,2)","v":""}]
[null,null,null,"　　　　年　　　月　　　日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　年　　　月　　　日　（時間　　　：　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査の20分前に受付をしてください"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査前",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査中",null,null,null,null,null,null,null,null,null,null,null,null,null,"検査後"]
[null,"食事",null,null,null,"夕食は午後７時頃までに\nお済ませ下さい。\n　※油分を控えた消化の良いもの\n（胃の手術を受けられた方は、\n　流動食をお勧めします。）",null,null,null,null,null,null,null,null,null,null,null,null,null,"朝食は何も召し上がらないでください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜検査前の確認・注意事項等＞",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査１時間後より消化の良い食事が可能です。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・検査前に血圧を測ります。\n・検査手順のパネルをご覧ください。\n　※予約時間の順にお呼びしますが、\n　　検査内容により、順番が前後する\n　　事が有ります。"]
[]
[]
[]
[null,"水分",null,null,null,"夕食後からは以下のもののみ摂取可能です。\n　※水・お茶・スポーツドリンク",null,null,null,null,null,null,null,null,null,null,null,null,null,"検査予約時間の１時間前(　：　)\nまでは、水･白湯が飲めます。\n　※水は胃内の粘膜をきれいにします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査１時間後より水分摂取が可能です。\n炭酸飲料は避けて下さい。"]
[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,"＜検査前の確認・注意事項等＞"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・鼻の通りをよくするお薬を点鼻します。\n・胃をきれいにする水薬を飲みます。\n・鼻とのどに麻酔のスプレーをします。"]
[null,"薬",null,null,null,"内服されている場合は、普段通り継続して下さい。",null,null,null,null,null,null,null,null,null,null,null,null,null,"心臓、血圧、喘息等の薬は起床時に服用して下さい。\nその他の薬は、服用しないで下さい。",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,"食事開始に伴って、服用できます。"]
[]
[]
[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,null,null,"↓"]
[null,"注意事項",null,null,null,"問診票の記入は治療中の病気、\n内服薬など詳しく記入して下さい。\n（お薬手帳又は薬の説明書を\n　ご用意下さい。）",null,null,null,null,null,null,null,null,null,null,null,null,null,"ガードルなど身体を締め付ける服装は避けて下さい。（内視鏡検査に不向きなため）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"＜検査＞",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医師より、検査結果の説明があります。"]
[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,null,null,"・仰向けから左側を下にして、膝・腰\n　を曲げ、楽な姿勢をとります。\n・医師がスコープを鼻から挿入し、\n　空気を入れながら検査をします。\n・必要があれば色素を散布して、組織\n　を採取します。\n・空気を抜いて、検査終了となります。\n\n※鼻から入らなかった場合、口からの\n　検査に切り替えます。"]
[]
[]
[]
[null,null,null,"血液を止まりにくくする薬を内服中の方へ\n※必ず当日、お薬の内容が分かるものを持参してください。\n※ワーファリンを内服している方は、組織検査は行えません。\n\nパーキンソン病の薬を内服中の方へ\n※お薬の内容によって経鼻内視鏡をお受けできない場合があります。\n　その場合は経口内視鏡に変更いたします。ご了承ください。\n\n血圧制限について\n※当日の血圧が、180/110mmHg以上の方は内視鏡検査を受けられません。\n\n体重制限について\n　※体重が135kg以上の方は内視鏡検査を受けられません。\n\n※キシロカインアレルギーのある方は、内視鏡検査を受けられません。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"看護師より、検査後の注意点の説明があります。"]
[]
[]
[]
[]
[]
[]
[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,null,null,"[組織検査を行った場合]\n　結果が出るまでに２週間ほどお時間\n　を頂きます。結果はご紹介元へ郵送\n　いたします。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査の影響が２～３時間続くことがあります。"]
[]
[]
[]
[]
[]
[]
[]
[null,"　お問い合わせ：渕野辺総合病院　内視鏡室",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【電話】０４２-７５４－２２２２（代表）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【時間】１４：００　～　１７：００（土、日、祝日を除く）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,null,null,"※キシロカインアレルギーのある方は、内視鏡検査を受けられません。"]

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[null,null,"患者氏名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,"（渕野辺総合病院用）"]
[]
[null,"上部消化管内視鏡検査（経鼻）　説明・同意書（3-①）"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(TRIM(AV5)<>\"\",AV5,TEXT(TODAY(),\"YYYY/MM/DD\"))","v":"&TagXrayStartDate&"}]
[null,"(説明内容)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"MID(AV6,1,4)","v":"&Tag"}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"MID(AV6,6,2)","v":"ra"}]
[null,"１）上部消化管内視鏡検査について",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"MID(AV6,9,2)","v":"St"}]
[null,null,"この検査では、食道・胃・十二指腸までの上部消化管を、医師の目で直接観察しながら検査を行うことができます。上部消化管にできる病気(ポリープ・がん・炎症など)を発見し、適切な治療方法を選択するために行います。\n注意：咽頭(のど)・呼吸器・心臓の疾患・高血圧・肝障害で治療中の方、明らかに出血傾向のある方、アレルギー体質の方は医師にご相談ください。",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,"こちらへ入力して\nいただくと、\n自動で２枚目に\n反映されます。\n"]
[]
[]
[]
[]
[]
[null,"２）検査内容"]
[null,null,"内視鏡を挿入し、診断します。検査中病変が見つかった場合、疑わしい場合は、必要に応じ以下の処置を追加する場合があります。\n（１）病変の一部をつまみ、組織を採って詳しく検査(生検)します。\n　※ワルファリン(ワーファリン等)を服用されている方は、組織検査(生検)を行えません。\n（２）病変に色素を散布し、診断の助けとする場合があります。"]
[]
[]
[]
[]
[]
[null,"３）偶発症について"]
[null,null,"（１）内視鏡による粘膜障害・裂傷・穿孔(穴が開くこと)\n（２）生検による出血\n（３）前処置の薬剤によるアレルギー等\n（４）検査前からあった疾患の悪化（症状の出ていなかった疾患も含む）等\n偶発症の発生する頻度は、消化器内視鏡学会の偶発症全国調査によると、上部消化管内視鏡検査における偶発症発生は11,265,684件中782件0.007％で、死亡は13件0.00012％と報告されています。当院では偶発症防止に十分な注意を払うとともに、万一の偶発症については最善の対応をいたします。"]
[]
[]
[]
[]
[]
[]
[null,"４）質疑応答"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"&tagPatName&"]
[null,null,null,"上記医療につき、患者様に説明いたしました。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"&tagPatKanaName"]
[]
[null,null,null,null,"西暦　　　　　年　　　月　　　日　　　　　主治医（ご紹介医）"]
[]
[]
[]
[]
[null,"　渕野辺総合病院　　病院長殿",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"西暦",null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[null,"　私は、上記の医療の説明を受け、質問をする機会を得て、内容を理解いたしました。また、上記の"]
[null,"医療を行う上で必要な処置、及び上記の医療において予期されない状況が発生した場合には、"]
[null,"それに対処する緊急処置を受けることも併せて"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□　同意します",null,null,null,null,null,null,null,null,null,"□　同意しません"]
[]
[null,"患者氏名"]
[]
[null,"または、親族及び理解補助者（理解者・父母・配偶者・兄弟姉妹・保護義務者・法定代理人）"]
[]
[null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（受診者との関係",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（患者さん用）"]
[]
[null,"上部消化管内視鏡検査（経鼻）　説明・同意書（3-②）"]
[null,null,null,null,null,null,null,"検査予定日",null,null,null,null,"西暦",null,null,{"$f":"IF(P5<>\"\",P5,\"\")","v":""},null,null,null,"年",null,{"$f":"IF(V5<>\"\",V5,\"\")","v":""},null,null,"月",null,{"$f":"IF(AA5<>\"\",AA5,\"\")","v":""},null,null,"日"]
[]
[null,"(説明内容)"]
[]
[null,"１）上部消化管内視鏡検査について"]
[null,null,{"$f":"IF(C10<>\"\",C10,\"\")","v":"この検査では、食道・胃・十二指腸までの上部消化管を、医師の目で直接観察しながら検査を行うことができます。上部消化管にできる病気(ポリープ・がん・炎症など)を発見し、適切な治療方法を選択するために行います。\n注意：咽頭(のど)・呼吸器・心臓の疾患・高血圧・肝障害で治療中の方、明らかに出血傾向のある方、アレルギー体質の方は医師にご相談ください。"}]
[]
[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,"１枚目に入力して\nいただくと、\n自動でこちらへ\n反映されます。\n"]
[]
[]
[]
[null,"２）検査内容"]
[null,null,{"$f":"IF(C17<>\"\",C17,\"\")","v":"内視鏡を挿入し、診断します。検査中病変が見つかった場合、疑わしい場合は、必要に応じ以下の処置を追加する場合があります。\n（１）病変の一部をつまみ、組織を採って詳しく検査(生検)します。\n　※ワルファリン(ワーファリン等)を服用されている方は、組織検査(生検)を行えません。\n（２）病変に色素を散布し、診断の助けとする場合があります。"}]
[]
[]
[]
[]
[]
[null,"３）偶発症について"]
[null,null,{"$f":"IF(C24<>\"\",C24,\"\")","v":"（１）内視鏡による粘膜障害・裂傷・穿孔(穴が開くこと)\n（２）生検による出血\n（３）前処置の薬剤によるアレルギー等\n（４）検査前からあった疾患の悪化（症状の出ていなかった疾患も含む）等\n偶発症の発生する頻度は、消化器内視鏡学会の偶発症全国調査によると、上部消化管内視鏡検査における偶発症発生は11,265,684件中782件0.007％で、死亡は13件0.00012％と報告されています。当院では偶発症防止に十分な注意を払うとともに、万一の偶発症については最善の対応をいたします。"}]
[]
[]
[]
[]
[]
[]
[null,"４）質疑応答"]
[null,null,{"$f":"IF(C32<>\"\",C32,\"\")","v":""}]
[]
[null,null,null,"上記医療につき、患者様に説明いたしました。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"&tagPatKanaName"]
[]
[null,null,null,null,"西暦　　　　　年　　　月　　　日　　　　　主治医（ご紹介医）"]
[]
[]
[]
[]
[null,{"$f":"B41","v":"　渕野辺総合病院　　病院長殿"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"西暦",null,null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[null,"　私は、上記の医療の説明を受け、質問をする機会を得て、内容を理解いたしました。また、上記の"]
[null,"医療を行う上で必要な処置、及び上記の医療において予期されない状況が発生した場合には、"]
[null,"それに対処する緊急処置を受けることも併せて"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□　同意します",null,null,null,null,null,null,null,null,null,"□　同意しません"]
[]
[null,"患者氏名"]
[]
[null,"または、親族及び理解補助者（理解者・父母・配偶者・兄弟姉妹・保護義務者・法定代理人）"]
[]
[null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（受診者との関係",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（渕野辺総合病院用）"]
[]
[null,"上部消化管内視鏡検査（経鼻）　説明・同意書（3-③）"]
[]
[null,"上部消化管（食道・胃・十二指腸）内視鏡検査問診票"]
[]
[null,"検査日：",null,null,null,"西暦",null,null,{"$f":"IF(P5<>\"\",P5,\"\")","v":""},null,null,"年",null,{"$f":"IF(V5<>\"\",V5,\"\")","v":""},null,"月",null,{"$f":"IF(AA5<>\"\",AA5,\"\")","v":""},null,"日",null,"（","曜日",null,null,null,"）"]
[]
[]
[null,"お名前：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様"]
[]
[null,"検査の日、ご家族への連絡先：電話　　　  　　－　　  　 　　　－　　　　　　お名前　　　　　　　　　　　　　　　様"]
[]
[null,"内視鏡検査を安全に行うために、できるだけ詳しくご記入ください。"]
[null,"質問事項",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"お答え"]
[null,"①　上部内視鏡検査（胃カメラ）を受けたことはありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"はいの方：",null,null,null,"当院　　　　　回、　他院　　　　　回    "]
[null,"　　検査の後ご気分が悪くなったことはありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"はいの方：",null,null,null,null,"どのようになりましたか"]
[null,"②　局所麻酔（抜歯、皮膚切開）を受けて気分が悪くなったことはありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"はいの方：",null,null,null,null,"どのようになりましたか"]
[null,"③　ヘリコバクター　ピロリ菌についてお尋ねします。当てはまるものに○をつけて下さい。"]
[null,null,null,"・陽性除菌未　　　・除菌成功　　　・除菌失敗　　　・陰性　　　・未検　　　・不明　　　・除菌判定前"]
[null,"④　血液の流れをよくする薬を飲んでいますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"はいの方：",null,null,null,"・バイアスピリン",null,null,null,null,null,null,null,null,"・バファリン",null,null,null,null,null,null,null,null,null,"・エフィエント",null,null,null,null,null,null,null,null,null,"・タケルダ"]
[null,null,null,null,null,"・パナルジン\n　(塩酸チクロジピン)",null,null,null,null,null,null,null,null,"・プラビックス\n　 (クロピドグレル)",null,null,null,null,null,null,null,null,null,"・ぺルサンチン\n　（ジピリダモール)",null,null,null,null,null,null,null,null,null,"・プレタール\n　(シロスタゾール)"]
[null,null,null,null,null,"・エパデール\n　(ｲｺｻﾍﾟﾝﾄ酸ｴﾁﾙ)",null,null,null,null,null,null,null,null,"・ロトリガ\n　(ｵﾒｶﾞ-3脂肪酸ｴﾁﾙ)",null,null,null,null,null,null,null,null,null,"・ドルナー\n　(ﾍﾞﾗﾌﾟﾛｽﾄﾅﾄﾘｳﾑ)",null,null,null,null,null,null,null,null,null,"・オパルモン\n　 (ﾘﾏﾌﾟﾛｽﾄｱﾙﾌｧﾃﾞｸｽ)"]
[null,null,null,null,null,"・ワーファリン",null,null,null,null,null,null,null,"・プラザキサ",null,null,null,null,null,null,null,"・リクシアナ",null,null,null,null,null,null,null,"・イグザレルト",null,null,null,null,null,null,null,"・エリキュース"]
[null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"　血液の流れを良くするお薬はいつまで飲みましたか？　　　　月　　 　日　　朝　　昼　　夜　まで飲みました。"]
[null,"⑤　手術を受けたことはありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"はいの方：",null,null,null,"  ・胃　　・大腸　　・虫垂　　・胆のう　　・子宮　　・卵巣　　・他　(　",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"⑥　現在治療中、または過去に治療・指摘を受けたことのある病気はありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"はいの方：",null,null,null,"・狭心症　　　・心筋梗塞　　　・不整脈　　　・高血圧　　　・高脂血症　　　・緑内障　　　・高眼圧"]
[null,null,null,null,null,"・前立腺肥大症　　　・糖尿病　　　・褐色細胞腫　　　・腎疾患　　　・血小板減少症　　　・肝疾患"]
[null,null,null,null,null,"・脳梗塞　　・甲状腺機能亢進症　　・パーキンソン病　　・気管支喘息　　・リウマチ　　・花粉症"]
[null,null,null,null,null,"その他（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"⑦　現在常用している薬(点眼薬含む)はありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"はいの方：",null,null,null,null,"何を飲んでいますか"]
[null,"⑧　薬品・食品のアレルギーはありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"はいの方：",null,null,null,null,"何に"]
[null,"⑨　女性の方、現在妊娠していますか？　妊娠の可能性はありますか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"　　　　　　　　　授乳中ですか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"はい",null,null,null,"いいえ"]
[null,"＊現在服用中のお薬手帳や薬の説明書もご持参ください"]
[null,"＊検査当日はこの問診票を忘れずに提出してください"]