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{"sheet":"訪問診療申込書","index":0,"n_rows":29,"n_cols":17,"rows_kept":29,"cut":false,"hidden":false,"merged":[[15,14,15,16],[16,2,16,7],[16,15,16,16],[4,11,4,12],[10,11,10,12],[11,11,11,12],[12,1,13,16],[9,0,9,1],[8,0,8,1],[5,0,7,0],[1,11,1,12],[12,0,13,0],[14,0,14,1],[17,0,17,1],[16,0,16,1],[15,0,15,1],[10,0,11,1],[15,2,15,8],[14,2,14,8],[1,0,1,3],[0,5,1,9],[18,14,18,16],[24,0,24,1],[22,0,22,1],[21,0,21,1],[20,0,20,1],[19,0,19,1],[18,0,18,1],[18,2,18,6]]}
[null,"は選択いただけます。",null,null,null,"訪問診療申込依頼書"]
["□はクリックすると✔が入力されます",null,null,null,null,null,null,null,null,null,null,"初回",null,"　  申込日：　　　年　　　月　　　日"]
["ふりがな",null,null,null,null,null,null,null,"在宅・病院・施設（病院または施設にお住まいの方は下もご記入ください。）",null,null,null,null,null,null,null,"在宅"]
["氏名",null,null,null,null,null,null,null,"病院名/施設名",null,"　　　　　　　　　　　　　　　　　　　　　　病室/入所階（　　）"]
["生年月日","昭和",60,"年",12,"月",12,"日","性別","男","介護保険","有（要支援1）"]
["住所","〒",null,null,null,null,null,null,"ケアマネージャー（事業者名）　　　　　　　　　　　　   （担当者名）"]
[null,null,null,null,null,null,null,null,"連絡先　（TEL）　　　　　　　　　　　　　　　　（FAX)"]
[null,null,null,null,null,null,null,null,"　　　　　　　　　　　　　　　　　　　　（電話番号）　　　　ー　　　　　ー　　　　"]
["キーパーソン",null,"ふりがな",null,null,null,null,null,"続柄（　　）",null,null,null,"　（電話番号）　　　　－　　　　　－"]
["（普段連絡を取れる方)",null,"氏名",null,null,null,null,null,null,null,null,null,"　（携帯番号）　　　　－　　　　　－"]
["治療希望理由",null,"（例：入れ歯が割れた・口腔ケア）",null,null,null,null,null,null,null,null,"デイサービス利用日："]
[null,null,null,null,null,null,null,null,null,null,null,"訪問（歯科）希望日："]
["現病歴","　　　　　　　　　　　　　　　　　　"]
[]
["普段飲んでいる薬"]
["歩行（移動など）",null,null,null,null,null,null,null,null,"ベッドからの移動ができない場合、体を起こす事"]
["食事形態",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・（　　　　　　）　"]
["うがい",null,null,null,null,null,null,null,null,"　ムセ有：食事の際にもムセはありますか。"]
["アレルギー",null,null,null,null,null,null,null,"アレルギーの種類：",null,null,null,null,null,"・その他（　 　 　　　　）"]
["血圧"]
["歯を抜いた時の異常"]
["肺炎の既往"]
["かかりつけの医院",null,null,null,null,null,null,null,null,"（電話番号）　　　　　－　　　　　　　－"]
[null,null,null,null,null,null,null,null,null,"  (電話番号）　　　　　－　　　　　　　－"]
["駐車スペース"]
["わかる範囲内でご記入いただければ結構です。その他、伝達事項がありましたら、余白にご記入ください。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"のだ歯科医院"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL:0568-62-7022"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX:0568-62-8796"]

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[]
["初回","在宅","大正","男","無","無","可"]
["2回目以降","病院","昭和","女","有（要支援1）","有","不可"]
[null,"施設","平成",null,"有（要支援2）"]
[null,null,"令和",null,"有（要介護1）"]
[null,null,null,null,"有（要介護2）"]
[null,null,null,null,"有（要介護3）"]
[null,null,null,null,"有（要介護4）"]
[null,null,null,null,"有（要介護5）"]