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[]
[null,null,"①診療情報提供書(βアミロイドPET検査)",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,null,null,null,null,null,null,null,null,"LSI札幌クリニック提出用"]
[]
[]
[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,"記入日",null,null,null,null,"年",null,null,null,"月",null,null,null,"日"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ご紹介医療機関",null,"名称"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所在地"]
[null,null,"札幌市東区北１３条東１丁目２番５０号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ＴＥＬ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"科　",false,"外来",null,false,"入院",null,"（",null,null,null,null,null,null,null,null,"）"]
[null,null,"ＬＳＩ ＩＤ 欄：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当医",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,"※押印の場合は3枚目まで押印下さい。"]
[]
[]
[null,"フリガナ\n受診者様氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,"性　　　　別",null,null,null,null,null,null,false,null,"男性",null,null,false,null,"女性"]
[]
[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,"生年月日",null,null,null,null,null,false,"大",false,"昭",false,"平",false,"令",null,null,null,"年",null,null,"月",null,null,"日"]
[null,"ご　　 住　　 所"]
[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,"連絡先※"]
[]
[null,"検　査　日　時",null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,null,null,null,"月",null,null,null,null,null,"日",null,"受付時間",null,null,null,null,null,null,null,null,null,null,null,null,"時",null,null,null,null,null,null,"分"]
[]
[]
[]
[null,"診断名"]
[]
[null,null,null,"軽度認知障害(MCI)",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,"軽度の認知症"]
[null,false,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,false]
[]
[null,"検査目的",null,null,null,null,null,null,null,null,"※いずれかにチェックをつけてください"]
[]
[]
[null,"レカネマブ",null,null,null,null,null,null,true,false,null,null,"[初回投与前]　投与の要否を判断"]
[]
[]
[null,true,null,null,null,null,null,null,null,false,null,null,"[投与中止後に初回投与から18カ月を超えて再開する場合]　投与の要否を判断　"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※本撮影が必要と判断した医学的根拠を「臨床経過・検査目的など」にご記入ください。"]
[null,"ドナネマブ",null,null,null,null,null,null,null,false,null,null,"[初回投与前]　投与の要否を判断",null,null,true]
[]
[]
[null,null,null,null,null,null,null,null,null,false,null,null,"[投与中止後に初回投与から18カ月を超えて再開する場合]　投与の要否を判断　"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※本撮影が必要と判断した医学的根拠を「臨床経過・検査目的など」にご記入ください。"]
[]
[null,null,null,null,null,null,null,null,null,false,null,null,"投与終了の可否を検討（投与開始後12か月を目安）"]
[null,null,null,null,null,null,null,null,null,false,null,null,"18か月を超える投与継続の可否を検討"]
[null,"確認事項",null,null,null,null,null,null,null,null,"※全ての項目にチェックがない場合、自費になります"]
[]
[]
[]
[null,false,null,"レカネマブまたはドナネマブ（遺伝子組換え）製剤に係る最適使用推進ガイドラインに準拠している施設である。"]
[]
[null,false]
[null,false,null,"効能又は効果としてアルツハイマー病による軽度認知障害及び軽度の認知症の進行抑制を有する医薬品に"]
[null,null,null,"係る厚生労働省の定める最適使用推進ガイドラインに沿って実施されるアミロイドPETである"]
[null,false,null,"認知機能の低下及び臨床症状の重症度範囲が以下の両方を満たしている"]
[]
[null,null,null,"MMSEスコア",null,null,null,null,null,null,"：",null,null,null,"点",null,null,"(",null,null,"年",null,null,"月",null,null,"日",")",null,"(レカネマブ：22点以上、ドナネマブ20-28点)"]
[null,null,null,"CDR全般スコア",null,null,null,null,null,null,"：",null,null,null,"点",null,null,"(",null,null,"年",null,null,"月",null,null,"日",")",null,"(0.5 又は　1.0)"]
[]
[]
[null,false,null,"1.5T以上の脳MRI検査を実施している　※MRI画像（CD-R)のご提出をお願いします"]
[null,"※上記の条件を満たしていない場合は、保険適用外となります。"]
[null,null,null,false,null,"【自費】保険外アミロイド検査　税込275,000円"]
[]
[]
[null,"臨床経過・検査目的など"]
[]
[]
[null,false,null,"別紙参照"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"■注意事項"]
[null,"・記載に不備がある場合は再提出をお願いすることがございます。"]
[null,"・保険適用がない場合、あるいは現在までの臨床情報では保険診療対象外と判断した場合には自費での受診をお願いすることがございます。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"酸素投与",null,null,null,null,null,false,"無",null,false,"有（",null,null,null,null,null,null,"ℓ／分）",null,null,"身長／体重",null,null,null,null,null,null,null,null,null,null,null,"㎝／",null,null,null,null,null,null,null,null,"㎏"]
[null,null,"受診者様情報"]
[null,null,null,null,null,null,null,null,null,null,"妊　　　　　娠",null,null,null,null,null,"妊娠中は検査不可",null,null,null,null,null,null,null,null,null,null,null,null,null,"ｱﾙｺｰﾙ不耐症",null,null,null,null,null,false,"無",null,false,"有（慎重投与）"]
[null,null,"（ 全 員 記 載 ）"]
[null,null,null,null,null,null,null,null,null,null,"移　　　　　動",null,null,null,null,null,false,"歩行",null,false,"車椅子",null,null,false,"ストレッチャー",null,null,null,null,null,"付　　　　　添",null,null,null,null,null,"約90分間お一人で待機出来ない方は必須"]
[]
[null,null,"次回来院日",null,null,null,null,null,null,null,null,null,null,"月",null,null,null,"日"]
[]
[]
[]
[]
[null,null,"②診療情報提供書(βアミロイドPET検査)",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,null,null,null,null,null,null,null,null,"ご紹介医療機関様 控え"]
[]
[]
[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,"記入日",{"$f":"IF(AM5=\"\",\"\",AM5)","v":""},null,null,null,"年",null,{"$f":"IF(AS5=\"\",\"\",AS5)","v":""},null,"月",null,{"$f":"IF(AW5=\"\",\"\",AW5)","v":""},null,"日"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ご紹介医療機関",null,"名称",null,null,null,null,{"$f":"IF(Y7=\"\",\"\",Y7)","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"所在地",null,null,null,null,{"$f":"IF(Y9=\"\",\"\",Y9)","v":""}]
[null,null,"札幌市東区北１３条東１丁目２番５０号"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ＴＥＬ",null,null,null,null,{"$f":"IF(Y11=\"\",\"\",Y11)","v":""},null,null,null,null,null,null,null,null,null,null,null,"ＦＡＸ",null,null,null,null,{"$f":"IF(AP11=\"\",\"\",AP11)","v":""}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"診療科",null,null,null,null,{"$f":"IF(Y13=\"\",\"\",Y13)","v":""},null,null,null,null,null,null,null,null,null,null,"科　",false,"外来",null,false,"入院",null,"（",{"$f":"IF(AR13=\"\",\"\",AR13)","v":""},null,null,null,null,null,null,null,"）"]
[null,null,"ＬＳＩ ＩＤ 欄：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当医",null,null,null,null,{"$f":"IF(Y14=\"\",\"\",Y14)","v":""},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,"※押印の場合は3枚目まで押印下さい。"]
[]
[]
[null,"フリガナ\n受診者様氏名",null,null,null,null,null,null,{"$f":"IF(I17=\"\",\"\",I17)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,"性　　　　別",null,null,null,null,null,null,false,null,"男性",null,null,false,null,"女性"]
[null,null,null,null,null,null,null,null,{"$f":"IF(I18=\"\",\"\",I18)","v":""}]
[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,"生年月日",null,null,null,null,null,false,"大",false,"昭",false,"平",false,"令",{"$f":"IF(AQ19=\"\",\"\",AQ19)","v":""},null,null,"年",{"$f":"IF(AU19=\"\",\"\",AU19)","v":""},null,"月",{"$f":"IF(AX19=\"\",\"\",AX19)","v":""},null,"日"]
[null,"ご　　 住　　 所",null,null,null,null,null,null,{"$f":"IF(I20=\"\",\"\",I20)","v":""}]
[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,"連絡先※",null,null,null,null,null,{"$f":"IF(AI21=\"\",\"\",AI21)","v":""}]
[]
[null,"検　査　日　時",null,null,null,null,null,null,{"$f":"IF(I23=\"\",\"\",I23)","v":""},null,null,null,null,null,"年",{"$f":"IF(P23=\"\",\"\",P23)","v":""},null,null,null,null,"月",{"$f":"IF(V23=\"\",\"\",V23)","v":""},null,null,null,null,"日",null,"受付時間",null,null,null,null,null,null,null,null,{"$f":"IF(AL23=\"\",\"\",AL23)","v":""},null,null,null,"時",null,null,{"$f":"IF(AS23=\"\",\"\",AS23)","v":""},null,null,null,"分"]
[]
[]
[]
[null,"診断名"]
[]
[null,null,null,"軽度認知障害(MCI)",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,"軽度の認知症"]
[null,false,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,false]
[]
[null,"検査目的",null,null,null,null,null,null,null,null,"※いずれかにチェックをつけてください"]
[]
[]
[null,"レカネマブ",null,null,null,null,null,null,null,null,null,null,"[初回投与前]　投与の要否を判断"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"[投与中止後に初回投与から18カ月を超えて再開する場合]　投与の要否を判断　"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※本撮影が必要と判断した医学的根拠を「臨床経過・検査目的など」にご記入ください。"]
[null,"ドナネマブ",null,null,null,null,null,null,null,null,null,null,"[初回投与前]　投与の要否を判断"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"[投与中止後に初回投与から18カ月を超えて再開する場合]　投与の要否を判断　"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※本撮影が必要と判断した医学的根拠を「臨床経過・検査目的など」にご記入ください。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"投与終了の可否を検討（投与開始後12か月を目安）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"18か月を超える投与継続の可否を検討"]
[null,"確認事項",null,null,null,null,null,null,null,null,"※全ての項目にチェックがない場合、自費になります"]
[]
[]
[]
[null,false,null,"レカネマブまたはドナネマブ（遺伝子組換え）製剤に係る最適使用推進ガイドラインに準拠している施設である。"]
[]
[null,false]
[null,null,null,"効能又は効果としてアルツハイマー病による軽度認知障害及び軽度の認知症の進行抑制を有する医薬品に"]
[null,null,null,"係る厚生労働省の定める最適使用推進ガイドラインに沿って実施されるアミロイドPETである"]
[null,false,null,"認知機能の低下及び臨床症状の重症度範囲が以下の両方を満たしている"]
[]
[null,null,null,"MMSEスコア",null,null,null,null,null,null,"：",{"$f":"IF(L59=\"\",\"\",L59)","v":""},null,null,"点",null,null,"(",{"$f":"IF(S59=\"\",\"\",S59)","v":""},null,"年",{"$f":"IF(V59=\"\",\"\",V59)","v":""},null,"月",{"$f":"IF(Y59=\"\",\"\",Y59)","v":""},null,"日",")",null,"(レカネマブ：22点以上、ドナネマブ20-28点)"]
[null,null,null,"CDR全般スコア",null,null,null,null,null,null,"：",{"$f":"IF(L60=\"\",\"\",L60)","v":""},null,null,"点",null,null,"(",{"$f":"IF(S60=\"\",\"\",S60)","v":""},null,"年",{"$f":"IF(V60=\"\",\"\",V60)","v":""},null,"月",{"$f":"IF(Y60=\"\",\"\",Y60)","v":""},null,"日",")",null,"(0.5 又は　1.0)"]
[]
[]
[null,null,null,"1.5T以上の脳MRI検査を実施している　※MRI画像（CD-R)のご提出をお願いします"]
[null,"※上記の条件を満たしていない場合は、保険適用外となります。"]
[null,null,null,false,null,"【自費】保険外アミロイド検査　税込275,000円"]
[]
[]
[null,"臨床経過・検査目的など"]
[]
[]
[null,false,null,"別紙参照"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"■注意事項"]
[null,"・記載に不備がある場合は再提出をお願いすることがございます。"]
[null,"・保険適用がない場合、あるいは現在までの臨床情報では保険診療対象外と判断した場合には自費での受診をお願いすることがございます。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,"酸素投与",null,null,null,null,null,false,"無",null,false,"有（",null,{"$f":"IF(W94=\"\",\"\",W94)","v":""},null,null,null,null,"ℓ／分）",null,null,"身長／体重",null,null,null,null,null,{"$f":"IF(AK94=\"\",\"\",AK94)","v":""},null,null,null,null,null,"㎝／",null,null,{"$f":"IF(AT94=\"\",\"\",AT94)","v":""},null,null,null,null,null,"㎏"]
[null,null,"受診者様情報"]
[null,null,null,null,null,null,null,null,null,null,"妊　　　　　娠",null,null,null,null,null,"妊娠中は検査不可",null,null,null,null,null,null,null,null,null,null,null,null,null,"ｱﾙｺｰﾙ不耐症",null,null,null,null,null,false,"無",null,false,"有（慎重投与）"]
[null,null,"（ 全 員 記 載 ）"]
[null,null,null,null,null,null,null,null,null,null,"移　　　　　動",null,null,null,null,null,false,"歩行",null,false,"車椅子",null,null,false,"ストレッチャー",null,null,null,null,null,"付　　　　　添",null,null,null,null,null,"約90分間お一人で待機出来ない方は必須"]
[]
[null,null,"次回来院日",null,null,null,null,null,null,null,null,{"$f":"IF(L100=\"\",\"\",L100)","v":""},null,"月",null,{"$f":"IF(P100=\"\",\"\",P100)","v":""},null,"日"]
[]
[]
[]
[]
[null,null,"③検査予約表",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受診者様用"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"記入日",{"$f":"IF(AM5=\"\",\"\",AM5)","v":""},null,null,null,"年",null,{"$f":"IF(AS5=\"\",\"\",AS5)","v":""},null,"月",null,{"$f":"IF(AW5=\"\",\"\",AW5)","v":""},null,"日"]
[]
[null,"フリガナ\n受診者様氏名",null,null,null,null,null,null,{"$f":"IF(I17=\"\",\"\",I17)","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,"連絡先※",null,null,null,null,null,{"$f":"IF(AI21=\"\",\"\",AI21)","v":""}]
[null,null,null,null,null,null,null,null,{"$f":"IF(I18=\"\",\"\",I18)","v":""}]
[]
[null,"検　査　日",null,null,null,null,null,null,{"$f":"IF(I23=\"\",\"\",I23)","v":""},null,null,null,null,null,"年",{"$f":"IF(P23=\"\",\"\",P23)","v":""},null,null,null,null,"月",{"$f":"IF(V23=\"\",\"\",V23)","v":""},null,null,null,null,"日",null,"受付時間",null,null,null,null,null,null,null,null,{"$f":"IF(AL23=\"\",\"\",AL23)","v":""},null,null,null,"時",null,null,{"$f":"IF(AS23=\"\",\"\",AS23)","v":""},null,null,null,"分"]
[]
[]
[null,"※上記ご連絡先に、検査日の前の週（水～金曜日）に当院からお電話いたします。"]
[]
[null,"注意事項"]
[]
[]
["【食事について】",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,"【薬について】"]
[]
[null,null,null,null,null,null,"・検査当日は\n　昼食は食べずにお越しください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・制限はありません"]
[]
[]
[]
[]
[null,null,null,null,null,null,"※アメやガムなども食べないでください。\n\n※飲み物は糖分の入っていない水か\n　お茶にしてください。",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"【女性の方へ】"]
[]
[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,"・妊娠中や妊娠の可能性の方は、\n　検査をお受けいただけません。"]
[]
[]
[]
[]
["【その他】"]
[]
[null,null,"・アルコールアレルギーをお持ちの方は事前にお申し出ください。\n・頭部に金属があると画像に悪影響を及ぼすため、検査時に外していただきます。\n・入れ歯は検査時に外していただきますので、入れ歯安定剤などの使用は控えてください。"]
[]
[]
[]
[]
["【検査について】"]
[]
[null,null,"・お薬を注射後、９０分安静にしていただきます。　その後、検査開始(撮影時間15～20分)となります。"]
[]
[]
[]
["【キャンセルについて】"]
[]
[null,null,null,null,null,null,"・特殊なお薬を使用します。キャンセルや日程変更は可能な限りお早めにご連絡ください。\n・連絡先：011-711-1331"]
[]
[]
[]
[]
[]
[]
["持ち物",null,null,null,null,null,null,null,"必  須",null,null,null,null,null,"　①検査費用(現金またはクレジットカード可)　②保険証　③本用紙"]
[]
[null,null,null,null,null,null,null,null,"お持ちの場合",null,null,null,null,null,"　④病院からのお手紙・CD　⑤おくすり手帳"]
[]
[]
[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,"地下鉄でお越しの方"]
[]
[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,"(東豊線)「北13条東駅」\n　　　　　　1番出口より徒歩30秒"]
[]
[]
[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,"(南北線)「北12条駅」\n　　　　　　2番出口より徒歩10分"]
[]
[]
[]
[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,"バスでお越しの方"]
[]
[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,"(東65・伏古北13条線)\n　　　　　 「北13条東１停留所」目の前"]
[]
[]
[]
[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,"お車でお越しの方"]
[]
[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,"　《無料駐車場がございます》"]
[]
[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,"・北13条北郷通を東に進む"]
[]
[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,"・北13東２を左折する"]
[]
[null,"札幌市東区北13条東1丁目2番50号",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,"・左手に入口がございます"]
[]
[null,"電話：011-711-1331(診療時間：平日、第1・3土曜日9時～17時)"]