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[null,"診療情報提供書（紹介状）"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
["社会医療法人北斗"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医療機関名"]
["北斗病院　／　北斗クリニック"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住　所"]
[]
[null,null,null,null,null,null,null,"科",null,null,null,null,null,null,null,"医師名"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX番号"]
[]
[]
[]
[]
[null,"ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生 年 月 日"]
[null,"患者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,"□","男",null,"□","大正","□","昭和",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□","女",null,"□","平成","□","令和"]
[null,"住    所",null,null,"〒"]
[null,"電話番号"]
[null,"自宅以外の連絡先（携帯等）"]
[]
[]
["紹介目的"]
[]
[]
["傷病名\n（主訴又は病名）"]
[]
[]
["既往歴及び\n家族歴"]
[]
[]
[]
["病状経過及び\n検査結果\n\n治療経過"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["現在の処方"]
[]
[]
[]
[]
[]
["その他留意事項等"]