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[null,null,null,null,null,"緊急連絡先",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,"歳）"]
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[null,null,null,null,null,null,null,null,null,null,null,"腫れ"]
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[null,null,null,null,null,"障　害\n疾　病\nその他",null,null,null,null,null,"身体"]
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[null,null,null,null,null,null,null,null,null,null,null,"知的"]
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[null,null,null,null,null,"意思の疎通",null,null,null,null,null,"困難",null,null,null,null,"良好",null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"過去の病気",null,null,null,null,null,"なし",null,null,null,null,"あり",null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"現在の病気",null,null,null,null,null,"なし",null,null,null,null,"あり",null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"服用して\nいる薬",null,null,null,null,null,"なし",null,null,null,null,"あり"]
[]
[null,null,null,null,null,"かかりつけ医療機関",null,null,null,null,"医療機関名",null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
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[null,null,null,null,null,"医師の意見書",null,null,null,null,null,"あり",null,null,null,null,"なし",null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"健康保険証",null,null,null,null,null,"あり",null,null,null,null,"なし",null,null,"（理由：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"手帳の有無",null,null,null,null,null,"なし",null,null,null,null,"あり",null,null,"（手帳の種類：",null,null,null,null,null,null,null,null,null,"）","等級",null,"（",null,null,"）級・度"]
["訪問診療を実施する場合",null,null,null,null,null,null,null,null,null,"都合が悪い曜日・時間",null,null,null,null,null,null,null,"（"]
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["第1号様式",null,null,null,null,"八王子市在宅要介護者等歯科診療受付票",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,"受付者",null,"関係",null,null,"性別",null,"要介護",null,"通院",null,null,"駐車場",null,"地区担当"]
[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,"今川",null,"子",null,null,"男",null,1,null,"（介助）",null,null,"有",null,"山内"]
["受付日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受付者",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"秋山",null,"妻",null,null,"女",null,2,null,"（車椅子）",null,null,"無",null,"丸山"]
[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,"鎌田",null,"夫",null,null,null,null,3,null,"（自立）",null,null,null,null,"奥富"]
["申込者",null,null,null,null,"フリガナ",null,null,null,"ハチオウジ　タロウ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"受診希望者との関係",null,null,null,null,null,null,null,null,null,null,null,"山北",null,"施設職員",null,null,null,null,4,null,null,null,null,null,null,"五藤"]
[null,null,null,null,null,"氏　名",null,null,null,"八王子　太郎",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"子",null,null,null,null,null,null,null,null,null,null,null,"植田",null,"ケアマネ",null,null,null,null,5,null,null,null,null,null,null,"氷見"]
[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,"加藤",null,"兄",null,null,null,null,null,null,null,null,null,null,null,"戸坂"]
[null,null,null,null,null,"連絡先",null,null,null,"042",null,null,null,null,null,"（","999",null,null,"）","9999",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"貝瀬",null,"弟"]
[null,null,null,null,null,"緊急連絡先",null,null,null,"042",null,null,null,null,null,"（","999",null,null,"）","9999",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"高島",null,"姉"]
["受診希望者",null,null,null,null,"フリガナ",null,null,null,"ハチオウジ　ハナコ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性　別",null,null,null,null,null,null,null,null,null,null,null,null,null,"妹"]
[null,null,null,null,null,"氏　名",null,null,null,"八王子　花子",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女",null,null,null,null,null,null,null,null,null,null,null,null,null,"本人"]
[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,"孫"]
[null,null,null,null,null,"住　所",null,null,null,"八王子市元本郷町3-24-1",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,null,null,null,null,null,null,null,null,"母"]
[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,"1940-02-02",null,null,null,null,null,null,null,null,null,null,null,null,null,"保健所職員"]
[null,null,null,null,null,"連絡先",null,null,null,"042",null,null,null,null,null,"（","888",null,null,"）","8888"]
[null,null,null,null,null,"緊急連絡先",null,null,null,"080",null,null,null,null,null,"（","888",null,null,"）","8888",null,null,null,null,null,null,null,null,"（",null,null,82,null,"歳）"]
["連絡先",null,null,null,null,"１.申込者　　　２.受診希望者　　　３.その他",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"名前：",null,"八王子　さくら",null,null,null,null,null,null,null,"関係：",null,"長女"]
[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,"070-777-7777"]
["受診希望者の状況",null,null,null,null,"症　状\n（主訴）",null,null,null,"具体的な状況",null,null,null,null,null,"入れ歯が合わず痛い。　　　　　　　　　　　　　　　　　すれて腫れている。　　　　　　　　　　　　　　　　　　入れ歯の調整をお願いしたい。"]
[null,null,null,null,null,null,null,null,null,null,null,"痛み"]
[null,null,null,null,null,null,null,null,null,null,null,"腫れ"]
[null,null,null,null,null,null,null,null,null,null,null,"その他"]
[null,null,null,null,null,"過去に受診\nした歯科",null,null,null,null,"医療機関名",null,null,null,null,"（","八王子市歯科",null,null,null,null,null,null,null,null,"）","最終受診日",null,null,null,"（","2020-05-05",null,null,null,null,null,"）"]
[null,null,null,null,null,null,null,null,null,null,"所在地",null,null,"（","八王子市元本郷町",null,null,null,null,null,null,null,null,null,null,"）","電話番号",null,null,null,"（","620-7292",null,null,null,null,null,"）"]
[null,null,null,null,null,"障　害\n疾　病\nその他",null,null,null,null,null,"身体",null,null,null,"内容：3年前脳梗塞になったことぬより、半身不随となりその後寝たきりの状態。"]
[null,null,null,null,null,null,null,null,null,null,null,"精神"]
[null,null,null,null,null,null,null,null,null,null,null,"知的"]
[null,null,null,null,null,null,null,null,null,null,null,"その他"]
[null,null,null,null,null,"要介護度",null,null,null,null,null,"要介護",null,null,"（",4,null,"）",null,null,"要支援",null,null,null,null,"自立"]
[null,null,null,null,null,"食　事",null,null,null,null,null,"全介助",null,null,null,null,"一部介助",null,null,null,null,"自立",null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"排　泄",null,null,null,null,null,"全介助",null,null,null,null,"一部介助",null,null,null,null,"自立",null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"座　位",null,null,null,null,null,"不可能",null,null,null,null,"可　能",null,null,null,"（","背もたれがあれば大丈夫",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"通　院",null,null,null,null,null,"不可能",null,null,null,null,"可　能",null,null,null,null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"診察台への移動",null,null,null,null,null,"不可能",null,null,null,null,"可　能",null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"意思の疎通",null,null,null,null,null,"困難",null,null,null,null,"良好",null,null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"過去の病気",null,null,null,null,null,"なし",null,null,null,null,"あり",null,null,null,"（","脳梗塞",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"現在の病気",null,null,null,null,null,"なし",null,null,null,null,"あり",null,null,null,"（","高血圧",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"服用して\nいる薬",null,null,null,null,null,"なし",null,null,null,null,"あり",null,null,null,null,"サゲールA錠（10㎎）朝・夕、ビオフェルミン"]
[]
[null,null,null,null,null,"かかりつけ医療機関",null,null,null,null,"医療機関名",null,null,null,null,"（","はちおうじ総合病院",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,"所在地(",null,null,"八王子市元本郷町",null,null,null,null,null,null,null,null,null,null,null,"）","電話番号(",null,null,null,"621-3111",null,null,null,null,null,null,"）"]
[null,null,null,null,null,"医師の意見書",null,null,null,null,null,"あり",null,null,null,null,"なし",null,null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"健康保険証",null,null,null,null,null,"あり",null,null,null,null,"なし",null,null,"（理由：",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"手帳の有無",null,null,null,null,null,"なし",null,null,null,null,"あり",null,null,"（手帳の種類：",null,null,null,null,"障害者手帳",null,null,null,null,"）","等級",null,"（",1,null,"）級・度"]
["訪問診療を実施する場合",null,null,null,null,null,null,null,null,null,"都合が悪い曜日・時間",null,null,null,null,null,null,null,"（","月曜日10：00～16：00※デイサ－ビス"]
[null,null,null,null,null,null,null,null,null,null,"駐車場",null,null,"（","無",null,"）","（","近くにコインパーキング　1Ｈ100円あり",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["備　考",null,null,null,null,"ケアマネージャー氏名",null,null,null,null,null,null,null,"（","千野　利休",null,null,null,null,"）","連絡先電話番号",null,null,null,null,null,"（","620-9999",null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"ケースワーカー氏名",null,null,null,null,null,null,"（",null,null,null,null,null,"）","所属",null,"（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
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