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[]
["PET-CT検査依頼書（診療情報提供書）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"西暦",null,null,null,null,null,"年",null,null,"月",null,null,"日"]
["仙台厚生病院"]
["先端画像医学センター　担当医　殿"]
[null,null,null,null,null,null,null,"病院／医院／クリニック",null,null,null,null,null,null,null,null,null,null,null,null,null,"科",null,null,"医師名"]
[null,"外来通院中",null,null,null,null,null,null,"入院中"]
["検査予定\n（予約日時）",null,null,null,null,"西暦",null,null,null,null,null,"年",null,null,"月",null,null,"日","(",null,null,")曜日",null,null,null,null,"時",null,null,null,"分","来院"]
[]
["ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生年月日"]
["患者氏名",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,"年",null,null,null,"月",null,null,null,"日"]
["患者住所",null,null,null,null,"〒","（",null,null,null,null,null,"）",null,null,null,null,null,null,null,null,"電話番号（日中連絡の取れるところ・携帯）"]
[]
["  ＜ 臨 床 診 断 ＞"]
[null,"悪性腫瘍（早期胃癌を除く）",null,null,null,null,null,null,null,null,null,null,null,"（具体的に",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,"心サルコイドーシス",null,null,null,null,null,null,null,null,null,null,null,null,"大型血管炎の局在、活動性診断"]
[null,"てんかん",null,null,null,null,null,null,null,null,null,null,null,null,"虚血性心疾患での心筋生存性"]
["　＜臨床経過･現在の投薬内容など＞",null,null,null,null,null,null,null,null,null,null,null,null,null,"別紙参照"]
[]
[]
[]
[]
[]
["　PET検査歴　　 ",null,null,null,null,null,null,null,null,null,null,"※他施設",null,null,null,"（",null,null,null,null,null,null,null,null,null,"）"]
[" 腫瘍マーカー",null,null,null,null,null,null,"異常あり",null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,"異常なし"]
[" 病理診断",null,null,null,null,null,null,"確定",null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）",null,null,"未確定"]
["　・手術歴",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,null,"部位",null,"（",null,null,null,null,null,null,null,null,null,null,"）"]
["　・化学療法",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日　","終了"]
["　・放射線治療",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日　","終了"]
[" 同一月ガリウムシンチ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※有の場合検査できませんのでご注意下さい"]
[" 検査に必要な確認事項",null,null,null,null,null,null,null,null,"※必ず記入してください"]
[null,null,null,null,null,null,null,null,null,null,"身長",null,null,null,null,"cm，",null,"体重",null,null,null,null,"kg，",null,"血糖値",null,null,null,null,null,"mg/dl"]
[null,null,null,null,null,null,null,null,null,null,"WBC",null,"（",null,null,null,"）",null,null,"CRP",null,"（",null,null,null,"）"]
[null,null,null," 糖　尿　病",null,null,null,null,null,null,null,null,null,null,null,null,null,"　→ 使用薬剤名",null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,"）"]
[null,null,null," 妊　　　娠"]
[null,null,null," 感　染　症"]
[null,null,null,null,null,null,null,null,null,null,"HB","（",null,"）","(－･＋)　 HCV(－･＋)　 STS(－･＋)　　MRSA(－･＋)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※　(－･＋)はこちらをコピーして下さい　"]
[null,null,null,null,null,null,null,null,null,null,"Tbc排菌(－･＋)　 その他の留意すべき感染症(－･＋：",null,null,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," 腎機能障害"]
[null,null,null," 歩　　　行",null,null,null,null,null,null,null,null,null,null,null,null,"（　　車椅子、",null,null,null,null,null,null,"ストレッチャー）"]
[null,null,null," 点　　　滴",null,null,null,null,null,null,null,null,null,null,null,null,null,"　→ 使用点滴名",null,null,null,null,null,"(",null,null,null,null,null,null,")"]
[null,null,null," Ｏ2　使 用",null,null,null,null,null,null,null,null,null,null,null,null,"（",null,null,null,null,"）"]
[null,null,null," G-CSF 使用"]
[null,null,null,"埋込型心臓ペースメーカ・除細動器の有無"]
[null,null,null,null,"CT検査の可否"]
[null,null,null,null,"設定変更"]
[null,null,null,null,"CT検査後ペースメーカチェック"]
[null,null,null," 認　知　症"]
[null,null,null," 30分程度の静止（仰向け）　"]
[" その他留意事項"]
[]
[]
[" 放射線科記入欄",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医　師"]
["医 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,null,null,"技　師"]
["Tel 022-222-7551　　Fax専用フリーダイヤル　0120-287-573　"]
[]
["患者さん控え",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様"]
[]
[]
["予約\n日時",null,null,null,"西暦　２０",null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,null,"（",null,null,null,null,null,"曜日）"]
[]
[]
[null,null,null,null,null,null,null,null,"時",null,null,null,null,null,"分",null,null,"受付",null,null,null,"食止め\n開始時刻",null,null,null,"（",null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[null,null,null,"●受付、診察の時間を考慮しております。この時間までに本館受付へお越しください。"]
[]
["■検査当日にご持参いただくもの"]
["　◇健康保険証並びに各種受給者証"]
["　◇検査料金（クレジットカードは使用出来ません）"]
["　　費用は保険適用の場合、3割負担で約3万円です。"]
["　◇診療情報提供書"]
["　◇その他、紹介元医療機関からの文書や検査などのデータ"]
["　◇ペースメーカー・ICD手帳（お持ちの方のみ）"]
[]
["■PET-CT検査の流れ"]
[]
[]
[]
[]
["　◇受付から検査終了まで3時間程度かかります。自然災害による機器の不具合・薬剤調達困難のため"]
["　　検査が中止となり、再度別日に検査が変更となることがあります。あらかじめご了承下さい。"]
[]
["■検査にあたってのご注意"]
["　◇検査受付の４時間前から絶食してください。"]
["　　※心臓サルコイドーシス検査目的の方は食止め時間は以下となります。ご注意ください。\n　"]
["　　　検査受付時間の、21時間前から炭水化物禁止、16時間前から絶食です（水のみ可）。"]
[]
["　◇あめやガムも検査に影響します。飲物は水だけにしてください。スポーツ飲料や牛乳など糖分を"]
["　　含む物は口にしないでください。検査が出来なくなる可能性があります。"]
[]
[]
["　◇紙おむつ、尿取りパット、生理用ナプキン、ストーマ用パウチ、尿管カテーテル、等を使用中の方は"]
["　　替えをお持ちください。場合により、検査前に交換していただきます。   "]
[]
["　◇ご来院の際は、出来るだけ自家用車か公共交通機関をご利用ください。検査前に長い距離を歩いたり、"]
["　　自転車に乗ったりされると筋肉に検査のお薬が集まって正確な診断ができないこともあります。"]
[]
["　◇撮影は20分程で終了しますが、医師の判断により追加の撮影を行う場合があります。痛みなどで\n"]
["　　長く仰向けになることが困難な方はご相談ください。頓服の痛み止めを飲んでいる方はご持参下さい。"]
[]
["　◇車椅子、ストレッチャーが必要な方はお知らせください。"]
[]
["　◇安全に検査を受けていただくため、トイレや移動に見守りまたは介助が必要な方、認知症の方は、"]
["　　ご家族の付きそいをお願いいたします。"]
[]
["　◇糖尿病治療を受けられている方は事前にお知らせ下さい。検査のために休薬が必要になるお薬があります。"]
[]
["　◇検査結果は、紹介元担当医師に郵送いたします。担当医師から結果の説明をお受け下さい。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〒981-0873　宮城県仙台市青葉区広瀬町4番15号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL　022-222-6181（代表）　8：30～17：15（平日のみ）"]