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[]
[null,"造影CT 検査同意書",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"IF(AO3=\"\",AO4,AO3)","v":"@REQUESTNAME"}]
[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,null,null,null,null,null,null,"@REQUESTNAME"]
[null,null,"検査予定日",null,null,null,null,null,null,null,"　　　　　年　　月　　日（　）　　　　　　　　　時　　分　より",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,"@USERNAME"]
[]
[null,null,null,"氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様"]
[null,null,"患者ID",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",null,null,null,null,"年令",null,null,null,null,null,null,"身長（",null,null,null,null,null,null,"ｃｍ）"]
[null,null,"依頼",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,"体重（",null,null,null,null,null,null,"Ｋｇ）"]
[]
[null,"検査を受けるに際し必ず別紙の注意事項を読み、以下の質問にお答えください。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"いいえ",null,null,null,"はい",null,null,null,null,"＜「はい」とお答えの方＞"]
[null,null,"①薬のアレルギーがありますか？",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,"　\n造影検査で副作用を生じる可能性が高いといえます。　\n　　　　　　　↓\n副作用について十分理解されたうえで、担当医と検査の可否を相談してください。"]
[null,null,"②気管支喘息と言われた事はありますか？"]
[null,null,"③甲状腺障害を指摘されたことがありますか？"]
[null,null,"④（女性のみ）妊娠中または授乳中ですか？"]
[null,null,"⑤糖尿病のお薬は飲んでいますか？"]
[]
[null,null,"⑥造影剤の副作用について理解されましたか？",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　はい　・　いいえ"]
[]
[null,null,"● 腎機能の確認：血清クレアチニン値",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"mg/dL",null,null,"→","規定値を超えた場合\n（　検査中止　・　了承の下施行　）"]
[]
[null,null,null,"※男性で1.7以上､女性で1.3以上(eGFR30以下)の場合にはリスクが高いため、原則造影検査は行いません"]
[null,null,null,"※検査日より原則３ヵ月以内のデータで記載の無い場合には、安全のため造影検査は行いません"]
[]
[null,null,"●","状態により放射線科医の判断で造影剤を使用しない単純CT検査としたり、検査を中断・中止する場合があります"]
[null,"　　 ","●","入院患者様は今回の入院期間中、治療に伴う経過観察のため、医師の判断により複数回造影CT検査を行う事があります"]
[]
[]
[]
[null,null,"実施日　　",null,null,null,"　　　年　 月　 日"]
[null,null,"説明日　　",null,null,null,"　　　年　 月　 日",null,null,null,null,null,null,null,null,null,"説明者　：　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,null,null,null,null,null,null,null,null,"　　　　：　看護師（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,null,"説明文書の交付を受けて説明を受けました。実施に必要な処置と造影CT検査をうけること、実施中に緊急処置を行う必要が生じた場合には、適宜処置されることについても併せて　　"]
[]
[null,null,null,"□","同意します  （同意された後もいつでも撤回することは可能です）"]
[]
[null,"　",null,"□","同意しません（検査しないことによる不利益に関して、主治医・病院に責任を問いません）"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入日：平成　 　　年　　　　月　　　　日"]
[null,"　",null,null,null,null,null,null,null,null,null,null,null,null,null," 本人氏名　：（　　　　　　　　　　）　"]
[null,"　　",null,null,null,null,null,null,null,null,null,null,null,null,null,"親族または代理者氏名　：（　　　   　　　 　　　）　"]
[null,null,null,null,null,"（ 本人との関係 ：父母、配偶者、子、兄弟姉妹、保護義務者、法的代理人、その他    　  　           )"]
[null,"　"]