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["診療情報提供書    乳腺・内分泌外科紹介用"]
[]
[]
["長野市民病院御中",{"$nulls":30},"年",null,null,"月",null,null,"日"]
["紹介元医療機関\n紹介医師氏名\n（住所・電話番号）"]
[]
[]
[]
[{"$nulls":27},"(TEL",{"$nulls":9},")"]
["患者情報",null,null,"フリガナ",{"$nulls":14},"男",null,"生年月日",{"$nulls":11},"（",null,null,"歳）"]
[{"$nulls":3},"氏名",{"$nulls":16},"明","・","大","・","昭","・","平","・","令",null,null,"年",null,null,"月",null,null,"日"]
[{"$nulls":18},"女"]
[]
[{"$nulls":3},"住所",null,null,"（〒",{"$nulls":4},"-",{"$nulls":3},"）"]
[]
[]
[{"$nulls":26},"(TEL",{"$nulls":10},")"]
[]
["【症状】該当するものに○印をお願いいたします。",{"$nulls":17},"乳房のしこり",{"$nulls":5},"/","乳頭分泌（血性、その他）"]
[]
[{"$nulls":4},"乳房の痛み",{"$nulls":5},"/","乳房の腫脹",{"$nulls":5},"/","マンモグラフィ検診",{"$nulls":5},"/","乳房超音波検診",{"$nulls":5},"/","その他"]
[]
["【紹介理由】（□に1つチェックをつけてください）",{"$nulls":20},"【緊急度】（□に1つチェックをつけてください）"]
[{"$nulls":14},"（","右",null,"・","左",null,"）",null,null,"至急（翌診療日）の予約依頼"]
[]
[{"$nulls":14},"（","右",null,"・","左",null,"）",{"$nulls":6},"週間以内"]
[]
[{"$nulls":14},"（","右",null,"・","左",null,"）",null,null,"いつでも良い"]
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[{"$nulls":14},"（","右",null,"・","左",null,"）"]
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[{"$nulls":14},"（","右",null,"・","左",null,"）"]
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["【部位】",{"$nulls":24},"しこりの大きさ（単位cm)"]
[]
[{"$nulls":29},"×",{"$nulls":3},"×"]
[]
[{"$nulls":26},"その他　記載欄"]
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["長野市民病院　地域医療連携室（直通）　ＦＡＸ：0120-115-295　ＴＥＬ：026-295-1611"]