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[null,"ＣＡ１９－９","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）"]
[]
[]
[null,"腹部ＣＴ",null,null,null,null,null,"異常(＋,－)",null,null,null,null,null,"異常(＋,－)"]
["画像","胸部ＣＴ",null,null,null,null,null,"異常(＋,－)",null,null,null,null,null,"異常(＋,－)"]
[null,"ＣＦ"]
[]
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[null,"再発所見","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）"]
[]
[]
["処方",null,"（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )"]
["備考（特記事項）"]
[]
[null,null,null,null,null,null,null,null,null,"刈谷豊田総合病院　地域連携室　FAX：0566ー27－6956"]
[null,null,null,null,null,null,null,null,null,null,"（がん治療連携指導料300点算定できます）"]
["データ記入用紙",null,null,null,null,null,"補助化学療法：",null,"ステージ：",null,null,null,"は基幹病院で"]
["かかりつけ医：",null,null,null,null,null,"患者ID：",null,"患者氏名："]
[]
[null,null,55,56,57,58,59,"５年後"]
[null,"(　月/日）","（　　/     )","（　　/     )","（　　/     )","（　　/     )","（　　/     )","（　　/     )"]
["バイタル","体温","（　　　　℃）","（　　　　℃）","（　　　　℃）","（　　　　℃）","（　　　　℃）","（　　　　℃）"]
[null,"血圧","（　　/     )","（　　/     )","（　　/     )","（　　/     )","（　　/     )","（　　/     )"]
[null,"体重","（　　   kg )","（　　   kg )","（　　   kg )","（　　   kg )","（　　   kg )","（　　   kg )"]
[null,"ＰＳ","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４"]
["診察","食欲不振","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４"]
[null,"悪心嘔吐","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４"]
[null,"下痢","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４","０・１・２・３・４"]
[]
["検査","Ｈｂ","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）"]
[null,"ＣＥＡ","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）"]
[null,"ＣＡ１９－９","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）","（　　　　）"]
[]
[]
[null,"腹部ＣＴ",null,null,null,null,null,"異常(＋,－)"]
["画像","胸部ＣＴ",null,null,null,null,null,"異常(＋,－)"]
[null,"ＣＦ"]
[]
["確認","イレウス","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）"]
[null,"再発所見","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）","（有・無）"]
[]
[]
["処方",null,"（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )","（ ＋,  -  )"]
["備考（特記事項）"]
[]
[null,null,null,"刈谷豊田総合病院　地域連携室　FAX：0566ー27－6956"]
[null,null,null,null,"（がん治療連携指導料300点算定できます）"]