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{"sheet":"☆依頼票(原本)","index":0,"n_rows":42,"n_cols":18,"rows_kept":42,"cut":false,"hidden":false,"merged":[[34,3,34,17],[35,3,35,17],[36,3,36,17],[0,1,0,17],[30,3,30,17],[31,3,31,17],[32,3,32,17],[33,3,33,17],[10,17,11,17],[5,11,5,17],[6,11,6,17],[7,11,7,17],[34,1,36,2],[22,12,23,12],[22,13,23,17],[24,6,24,9],[41,1,41,17],[12,1,13,2],[12,8,13,8],[12,10,13,10],[12,12,13,12],[12,11,13,11],[12,13,13,13],[12,14,13,14],[12,15,13,15],[12,9,13,9],[12,7,13,7],[26,3,26,7],[26,8,26,12],[26,13,26,17],[29,1,33,2],[21,10,24,11],[23,6,23,8],[25,1,28,2],[18,1,20,2],[21,6,21,8],[22,6,22,8],[21,1,24,2],[15,1,15,2],[10,1,10,2],[11,1,11,2],[14,1,14,2],[10,14,11,14],[14,3,14,17],[15,3,15,11],[10,15,11,15],[10,16,11,16],[4,11,4,17],[11,3,11,13],[10,3,10,13]]}
[null,"診療情報提供書 兼 栄養食事指導依頼票"]
[null,null,null,null,null,null,null,null,null,null,null,"令和",null,"年",null,"月",null,"日"]
[]
[null,"【紹介先医療機関】",null,null,null,null,null,null,"【紹介元医療機関】"]
[null,"山形ロイヤル病院",null,null,null,null,null,null,null,null,"医療機関名："]
[null,"東根市大森2丁目3-6",null,null,null,null,null,null,null,null,"医師名："]
[null,"TEL：0237-43-8080",null,null,null,null,null,null,null,null,"TEL："]
[null,"FAX：0237-43-8227",null,null,null,null,null,null,null,null,"FAX："]
[]
[null,"【紹介患者情報】"]
[null,"ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,"□","男","□","女"]
[null,"氏名"]
[null,"生年月日",null,"□","大正","□","平成",null,"年",null,"月",null,"日","（",null,"歳）"]
[null,null,null,"□","昭和","□","令和"]
[null,"住所"]
[null,"電話番号",null,null,null,null,null,null,null,null,null,null,"※連絡のつく電話番号をご記入ください"]
[]
[null,"【栄養指導指示内容】"]
[null,"傷病名\n(指導病名)",null,"□","糖尿病",null,null,null,"□","糖尿病性腎症",null,null,"□","脂質異常症",null,null,"□","痛風"]
[null,null,null,"□","肥満症（BMI30以上）",null,null,null,"□","高血圧症",null,null,"□","慢性心不全"]
[null,null,null,"□","慢性腎不全",null,null,null,"□","低栄養",null,null,"□","摂食嚥下障害"]
[null,"指導指示",null,"□","エネルギー",null,null,null,null,"kcal","または"]
[null,null,null,"□","たんぱく質",null,null,null,null,"g",null,null,"□","病態に基づき適正栄養量を\n管理栄養士に算出させる"]
[null,null,null,"□","塩分",null,null,null,null,"g"]
[null,null,null,"□","その他"]
[null,"指導希望日",null,"※希望日は、依頼票作成から1週間以上期間を空けた日でご記入をお願いします。"]
[null,null,null,"第1希望日",null,null,null,null,"第2希望日",null,null,null,null,"第3希望日"]
[null,null,null,null,"月",null,"日",null,null,"月",null,"日",null,null,"月",null,"日"]
[null,null,null,"□","AM",null,"□","PM","□","AM",null,"□","PM","□","AM",null,"□","PM"]
[null,"特記事項",null,"※症状治療経過等をご記入ください。"]
[]
[]
[]
[]
[null,"現在の処方"]
[]
[]
[null,"※直近の採血データの添付をお願いいたします。"]
[null,"※指導希望日を確認し、当院より直接、紹介患者様へ日程のご相談をさせていただきます。"]
[null,"※栄養指導実施後は、FAXにてご報告させていただきます。"]
[]
[null,"【問い合わせ先：山形ロイヤル病院 栄養科（TEL 0237-43-8080 / FAX 0237-43-8227）】"]