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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"〈書式２　整形外科受診用〉"]
["Ｇ 骨密度（骨塩定量）検査申込書兼診療情報提供書"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日"]
["総合大雄会病院　整形外科　宛"]
[]
[]
["検査希望日",null,null,null,null,null,null,null,null,null,null,"医療機関名"]
["第１希望",null,null,"年",null,"月",null,"日","(",null,")","医師名",null,null,null,null,null,null,null,null,"㊞"]
["第２希望",null,null,"年",null,"月",null,"日","(",null,")","TEL"]
["第３希望",null,null,"年",null,"月",null,"日","(",null,")","FAX"]
[]
["ふりがな",null,null,null,null,null,null,null,null,null,null,"生年月日",null,null,null,null,null,"年齢",null,"性別"]
["患者氏名"]
[]
["〒"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL"]
[null,null,null,null,"身長",null,null,null,"cm",null,null,null,null,"体重",null,null,null,"kg"]
["検査部位"]
[]
["紹介目的",null,null,"　　　骨密度測定、必要時薬剤決定"]
[null,null,null,"　　　骨粗鬆症の治療依頼（導入時フォルテオ指導など）"]
[null,null,null,"　　　※治療を貴院で継続頂ける場合は貴院採用薬を記入してください。"]
[null,null,null,"　　　採用薬情報等"]
[null,null,null,"　"]
[]
[]
["オプション",null,null,null,1,"ＦＲＡＸ",null,null,null,2,null,"骨代謝マーカー",null,null,null,3,"体組織（筋肉量）"]
["（数字をダブルクリックすると○印がつきます）",null,null,null,4,"手、足など特別な部位測定",null,null,null,null,null,null,null,5,"半年後のＤＥＸＡ予約"]
[null,null,null,null,"特記事項等"]
[null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,null,"骨密度検査禁忌チェック"]
[null,"＊腰椎に金属を入れる手術をしたことがある"]
[null,"＊股関節に金属を入れる手術をしたことがある"]
[null,"＊最近バリウムの検査をしたことがある"]
[null,"＊妊娠の可能性がある"]
["*予約受診、お会計は総合大雄会病院となりますが、検査は大雄会クリニックで施行いたします。"]
["患者さまには移動でご不便をお掛けしますが、あらかじめご了承頂きますようご説明のほどよろしくお願いいたします。"]
["送付先　　総合大雄会病院　地域医療連携室　　　\n                                                         　 　",null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX 0586-24-9999"]
["※右記のFAX番号を確認後送信してください。",null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL 0586-26-2366（直通）"]
["※個人情報の取扱いについては慎重にお願いします。"]