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["紹介・診療情報提供書"]
[]
["宛先",{"$nulls":16},"平成　　年　　月　　日"]
["〒734-8551"]
["　","広島市南区霞一丁目２番３号"]
[null,"広 島 大 学 病 院"]
[{"$nulls":9},"紹介元医療機関名称等"]
[{"$nulls":14},"〒"]
[{"$nulls":10},"所在地"]
[{"$nulls":10},"医療機関名"]
[{"$nulls":10},"電話番号"]
[{"$nulls":10},"ＦＡＸ番号"]
[{"$nulls":10},"医師氏名",{"$nulls":13},"印"]
[]
[null," 患者氏名",{"$nulls":15},"性別　　男　・　女"]
[null," 生年月日",{"$nulls":3},"明・大・昭・平　　　年　　月　　日（　　歳）"]
[null," 患者住所",{"$nulls":3},"〒"]
[]
[null," 電話番号",{"$nulls":3},"（　　　　　）　　　　　－"]
[]
[null," 傷病名",null,null,"①",{"$nulls":8},"②"]
[{"$nulls":4},"③",{"$nulls":8},"④"]
[null," 紹介目的"]
[]
[]
[null," 既往症及び家族歴"]
[]
[null," 症状経過及び検査結果"]
[]
[]
[]
[]
[null," 治療経過"]
[]
[]
[]
[]
[null," 現在の処方"]
[]
[]
[]
[null," その他特記事項"]