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[null,"□心ｻﾙｺｲﾄﾞｰｼｽと診断されており、炎症部位の診断が必要",null,null,null,null,null,null,null,"□それ以外（自費）"]
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["撮影希望範囲",null,null,null,null,null,null,"※無い場合は頭頂部～鼠径部まで撮像致します。"]
["臨床経過","※必ずご記入をお願い致します。"]
["腫瘍マーカー\n病理検査"]
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["撮影希望範囲",null,null,null,null,null,null,"※無い場合は頭頂部～鼠径部まで撮像致します。"]
["臨床経過","※必ずご記入をお願い致します。"]
["腫瘍マーカー\n病理検査"]
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[]
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[null,null,null,null,null,null,null,null,null,"2021/4/16版"]

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[]
["撮影希望範囲",null,null,null,null,null,null,"※無い場合は頭頂部～鼠径部まで撮像致します。"]
["臨床経過","※必ずご記入をお願い致します。"]
["腫瘍マーカー\n病理検査"]
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[null,"□無","□有","血糖値","mg/dl","検査当日血糖値が230以上の場合検査実施の有無",null,null,null,null,null,"□実施","□中止"]
[]
["診療用放射線の安全利用に関するガイドラインにおいては、以下について患者様へご説明し、ご理解を得ることが必要とされています。\n☑ PET検査１回当たりの被ばく量は約3mSv(ミリシーベルト)、CT検査1回当たりの被ばく量は約2～10mSvです。ただし、体重や撮影部位により被ばく量は異なります。\n☑ 放射線被ばくによる不利益に比べ、検査を行う事により得られる利益が上回る場合に、当該放射線診療を実施します。\n☑ 湘南鎌倉総合病院では、医療被ばく低減のため、関係学会等の策定したガイドライン等を活用して線量を評価し、診療目的や画質等に関しても十分に考慮した上で、最適化を定期的に行っています。"]
[null,null,null,null,null,null,null,null,null,"2021/4/16版"]

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["先端医療センター　寺田 茂彦 先生",null,null,null,"宛",null,"所在地",null,"〒253-0052　茅ヶ崎市幸町14-1"]
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["患者氏名",null,null,null,null,null,null,null,"男・女","cm",null,"kg"]
["住所",null,null,null,null,null,null,null,"電話番号","自宅："]
[null,null,null,null,null,null,null,null,null,"携帯："]
["悪性腫瘍","＜疾患名＞",null,"□脳悪性腫瘍（　　        　　　）",null,null,null,"□頭頸部癌(           　　　　　癌)",null,null,null,"□肺癌","□乳癌"]
[null,"□食道癌",null,"□胃癌(早期癌は適応外)",null,null,"□大腸癌",null,"□GIST","□皮膚癌",null,"□悪性黒色腫"]
[null,"□膵臓癌",null,"□胆嚢癌・胆管癌",null,null,"□肝細胞癌",null,"□多発性骨髄腫"]
[null,"□悪性リンパ腫",null,"□腎癌",null,"□膀胱癌",null,"□骨・軟部組織悪性腫瘍（　　　　　）"]
[null,"□前立腺癌",null,"□子宮体癌",null,"□子宮頚癌",null,"□卵巣癌",null,"□その他(　　　　　　　　　　)"]
[null,"＜検査目的＞",null,"□病期診断",null,"□転移・再発診断",null,null,"□その他（自費）"]
["心ｻﾙｺｲﾄﾞｰｼｽ","□診断目的(心臓以外で類上皮細胞肉芽腫が陽性でｻﾙｺｲﾄﾞｰｼｽと診断され、かつ心臓病変を疑う心電図または心ｴｺｰ所見を認める)"]
[null,"□心ｻﾙｺｲﾄﾞｰｼｽと診断されており、炎症部位の診断が必要",null,null,null,null,null,null,null,"□それ以外（自費）"]
["大型血管炎","□他の検査で病変の局在また活動性の判断がつかない",null,null,null,null,null,null,null,"□それ以外（自費）"]
[]
["撮影希望範囲",null,null,null,null,null,null,"※無い場合は頭頂部～鼠径部まで撮像致します。"]
["臨床経過","※必ずご記入をお願い致します。"]
["腫瘍マーカー\n病理検査"]
[]
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["化学療法","□無","□有","最終",null,null,"年",null,"月頃","自立歩行",null,"□可","□車椅子"]
["放射線治療","□無","□有","最終",null,null,"年",null,"月頃","付き添い",null,"□無","□有"]
["1ケ月以内のG-CSF薬剤使用の有無",null,null,"□無","□有","最終",null,"年","月頃","30分間静止",null,"□可","□非"]
["検査当日体温が38.0℃以上の場合の検査実施有無",null,null,null,null,null,null,"□実施","□中止","閉所恐怖症",null,"□無","□有"]
["感染症有無","□無","□有  HBsAg ・HCVAb・その他：　　　　",null,null,null,null,null,"2週間以内のバリウム検査",null,null,"□無","□有"]
["糖尿病","※糖尿病薬剤については検査当日の服用(投与)を避けてください。",null,null,null,null,null,null,null,"ﾍﾟｰｽﾒｰｶｰ/ICD",null,"□無","□有"]
[null,"□無","□有","血糖値","mg/dl","検査当日血糖値が230以上の場合検査実施の有無",null,null,null,null,null,"□実施","□中止"]
[]
["診療用放射線の安全利用に関するガイドラインにおいては、以下について患者様へご説明し、ご理解を得ることが必要とされています。\n☑ PET検査１回当たりの被ばく量は約3mSv(ミリシーベルト)、CT検査1回当たりの被ばく量は約2～10mSvです。ただし、体重や撮影部位により被ばく量は異なります。\n☑ 放射線被ばくによる不利益に比べ、検査を行う事により得られる利益が上回る場合に、当該放射線診療を実施します。\n☑ 湘南鎌倉総合病院では、医療被ばく低減のため、関係学会等の策定したガイドライン等を活用して線量を評価し、診療目的や画質等に関しても十分に考慮した上で、最適化を定期的に行っています。"]
[null,null,null,null,null,null,null,null,null,"2021/4/16版"]

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[]
["住所","〒",null,null,null,null,null,null,"電話番号","自宅："]
[null,null,null,null,null,null,null,null,null,"携帯："]
["悪性腫瘍","＜疾患名＞",null,"　 脳悪性腫瘍（　　        　　　）",null,null,null,"　 頭頸部癌(           　　　　　癌)",null,null,null,"　 肺癌","　 乳癌"]
[null,"　食道癌",null,"　 胃癌(早期癌は適応外)",null,null,"　 大腸癌",null,"　 GIST","　 皮膚癌",null,"　 悪性黒色腫"]
[null,"　膵臓癌",null,"　 胆嚢癌・胆管癌",null,null,"　 肝細胞癌",null,"　 多発性骨髄腫"]
[null,"　悪性リンパ腫",null,"　 腎癌",null,"　 膀胱癌",null,"　 骨・軟部組織悪性腫瘍（　　　　　）"]
[null,"　前立腺癌",null,"　 子宮体癌",null,"　 子宮頚癌",null,"　 卵巣癌",null,"　その他(　　　　　　　　　　)"]
[null,"＜検査目的＞",null,"　 病期診断",null,"　 転移・再発診断",null,null," 　その他（自費）:"]
["心ｻﾙｺｲﾄﾞｰｼｽ","　  診断目的(心臓以外で類上皮細胞肉芽腫が陽性でｻﾙｺｲﾄﾞｰｼｽと診断され、かつ心臓病変を疑う心電図または心ｴｺｰ所見を認める)"]
[null,"　 心ｻﾙｺｲﾄﾞｰｼｽと診断されており、炎症部位の診断が必要",null,null,null,null,null,null,null," 　それ以外（自費）"]
["大型血管炎"," 　他の検査で病変の局在また活動性の判断がつかない",null,null,null,null,null,null,null," 　それ以外（自費）"]
[]
["撮影希望範囲",null,null,null,null,null,null,"※無い場合は頭頂部～鼠径部まで撮像致します。"]
["臨床経過\n腫瘍マーカー\n病理検査"]
["別紙可","※必ずご記入をお願い致します。"]
[]
["手術歴","　無 　有",null,"年",null,"月頃","術式：",null,null,"現在状況",null,"　 外来","　 入院中"]
[null,null,null,"年",null,"月頃","術式：",null,null,"経口摂取",null,"　 可","　 非"]
["化学療法","　無","　有","最終",null,null,"年",null,"月頃","自立歩行",null,"　 可"," 　 車椅子"]
["放射線治療","　無","　有","最終",null,null,"年",null,"月頃","付き添い",null,"　 無"," 　有"]
["1ケ月以内のG-CSF薬剤使用の有無",null,null,"　無 　有","最終",null,"年",null,"月頃","30分間静止",null," 　可","　 非"]
["検査当日体温が38.0℃以上の場合の検査実施有無",null,null,null,null,null,null,"　実施","　中止","閉所恐怖症",null,"　 無"," 　有"]
["感染症有無","　無","　有　　　","HBsAg","HCVAb","その他：",null,null,"2週間以内のバリウム検査",null,null," 　無","　 有"]
[null,"Wクリックで〇が付きます→"]
["糖尿病","※糖尿病薬剤については検査当日の服用(投与)を避けてください。",null,null,null,null,null,null,null,"ﾍﾟｰｽﾒｰｶｰ/ICD ",null," 　無","　 有"]
[null,"　無","　有","血糖値",null,"mg/dl","検査当日血糖値が230以上の場合検査実施の有無",null,null,null,null," 　実施","　 中止"]
[]
["診療用放射線の安全利用に関するガイドラインにおいては、以下について患者様へご説明し、ご理解を得ることが必要とされています。\n☑ PET検査１回当たりの被ばく量は約3mSv(ミリシーベルト)、CT検査1回当たりの被ばく量は約2～10mSvです。ただし、体重や撮影部位により被ばく量は異なります。\n☑ 放射線被ばくによる不利益に比べ、検査を行う事により得られる利益が上回る場合に、当該放射線診療を実施します。\n☑ 湘南鎌倉総合病院では、医療被ばく低減のため、関係学会等の策定したガイドライン等を活用して線量を評価し、診療目的や画質等に関しても十分に考慮した上で、最適化を定期的に行っています。"]
[null,null,null,null,null,null,null,null,null,"2021/5/24版"]

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[null,null,null,null,null,null,null,null,null,"携帯："]
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[null,"□食道癌",null,"□胃癌(早期癌は適応外)",null,null,"□大腸癌",null,"□GIST","□皮膚癌",null,"□悪性黒色腫"]
[null,"□膵臓癌",null,"□胆嚢癌・胆管癌",null,null,"□肝細胞癌",null,"□多発性骨髄腫"]
[null,"□悪性リンパ腫",null,"□腎癌",null,"□膀胱癌",null,"□骨・軟部組織悪性腫瘍（　　　　　）"]
[null,"□前立腺癌",null,"□子宮体癌",null,"□子宮頚癌",null,"□卵巣癌",null,"□その他(　　　　　　　　　　)"]
[null,"＜検査目的＞",null,"□病期診断",null,"□転移・再発診断",null,null,"□その他（自費）"]
["心ｻﾙｺｲﾄﾞｰｼｽ","□診断目的(心臓以外で類上皮細胞肉芽腫が陽性でｻﾙｺｲﾄﾞｰｼｽと診断され、かつ心臓病変を疑う心電図または心ｴｺｰ所見を認める)"]
[null,"□心ｻﾙｺｲﾄﾞｰｼｽと診断されており、炎症部位の診断が必要",null,null,null,null,null,null,null,"□それ以外（自費）"]
["大型血管炎","□他の検査で病変の局在また活動性の判断がつかない",null,null,null,null,null,null,null,"□それ以外（自費）"]
[]
["撮影希望範囲",null,null,null,null,null,null,"※無い場合は頭頂部～鼠径部まで撮像致します。"]
["臨床経過","※必ずご記入をお願い致します。"]
["腫瘍マーカー\n病理検査"]
[]
["手術歴","□無","□有","年","月頃","術式：",null,null,null,"現在状況",null,"□外来","□入院中"]
[null,null,null,"年","月頃","術式：",null,null,null,"経口摂取",null,"□可","□非"]
["化学療法","□無","□有","最終",null,null,"年",null,"月頃","自立歩行",null,"□可","□車椅子"]
["放射線治療","□無","□有","最終",null,null,"年",null,"月頃","付き添い",null,"□無","□有"]
["1ケ月以内のG-CSF薬剤使用の有無",null,null,"□無","□有","最終",null,"年","月頃","30分間静止",null,"□可","□非"]
["検査当日体温が38.0℃以上の場合の検査実施有無",null,null,null,null,null,null,"□実施","□中止","閉所恐怖症",null,"□無","□有"]
["感染症有無","□無","□有  HBsAg ・HCVAb・その他：　　　　",null,null,null,null,null,"2週間以内のバリウム検査",null,null,"□無","□有"]
["糖尿病","※糖尿病薬剤については検査当日の服用(投与)を避けてください。",null,null,null,null,null,null,null,"ﾍﾟｰｽﾒｰｶｰ/ICD",null,"□無","□有"]
[null,"□無","□有","血糖値","mg/dl","検査当日血糖値が230以上の場合検査実施の有無",null,null,null,null,null,"□実施","□中止"]
[]
["診療用放射線の安全利用に関するガイドラインにおいては、以下について患者様へご説明し、ご理解を得ることが必要とされています。\n☑ PET検査１回当たりの被ばく量は約3mSv(ミリシーベルト)、CT検査1回当たりの被ばく量は約2～10mSvです。ただし、体重や撮影部位により被ばく量は異なります。\n☑ 放射線被ばくによる不利益に比べ、検査を行う事により得られる利益が上回る場合に、当該放射線診療を実施します。\n☑ 湘南鎌倉総合病院では、医療被ばく低減のため、関係学会等の策定したガイドライン等を活用して線量を評価し、診療目的や画質等に関しても十分に考慮した上で、最適化を定期的に行っています。"]
[null,null,null,null,null,null,null,null,null,"2021/3/1版"]