유전학 검사 의뢰서 등록

의학유전학검사의뢰서(서울아산병원) 의뢰병원 담당의사 가계도

<line id="line3" class="line_3" style="x1:0px; y1:48px; x2:540px; y2:48px; "/>
			<line id="line4" class="line_3" style="x1:0px; y1:73px; x2:540px; y2:73px; "/>
			<line id="line5" class="line_3" style="x1:0px; y1:98px; x2:540px; y2:98px; "/>
			<line id="line7" class="line_3" style="x1:0px; y1:123px; x2:540px; y2:123px; "/>
			<line id="line9" class="line_3" style="x1:0px; y1:148px; x2:540px; y2:148px; "/>
			<line id="line10" class="line_3" style="x1:0px; y1:223px; x2:540px; y2:223px; "/>
			<line id="line12" class="line_3" style="x1:0px; y1:248px; x2:540px; y2:248px; "/>
			<line id="line16" class="line_1" style="x1:0px; y1:265px; x2:540px; y2:265px; "/>
			<caption id="caption18" class="cell_1" style="left:270px; top:50px; width:100px; height:23px; text-align:left; vertical-align:middle; ">의뢰일</caption>
			<caption id="caption19" class="cell_1" style="left:270px; top:25px; width:100px; height:23px; text-align:left; vertical-align:middle; ">진료과</caption>
			<input id="input12" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para2" style="left:372px; top:26px; width:168px; height:19px; "/>
			<input id="input13" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para4" class="input_s_essential" inputtype="date" style="left:372px; top:51px; width:165px; height:19px; font-weight:normal; "/>
			<caption id="caption2" class="cell_1" style="left:0px; top:75px; width:100px; height:23px; text-align:left; vertical-align:middle; ">전화번호</caption>
			<input id="input14" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para5" style="left:102px; top:76px; width:163px; height:19px; "/>
			<caption id="caption20" class="cell_1" style="left:270px; top:75px; width:100px; height:23px; text-align:left; vertical-align:middle; ">팩스번호</caption>
			<caption id="caption4" class="cell_1" style="left:0px; top:100px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">환자이름</caption>
			<caption id="caption6" class="cell_1" style="left:270px; top:100px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">주민등록번호</caption>
			<input id="input17" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para7" style="left:102px; top:101px; width:163px; height:19px; "/>
			<input id="input3" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para6" style="left:372px; top:76px; width:168px; height:19px; "/>
			<input id="input18" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para8" style="left:372px; top:101px; width:168px; height:19px; "/>
			<line id="line17" class="line_3" style="x1:0px; y1:173px; x2:540px; y2:173px; "/>
			<caption id="caption8" class="cell_1" style="left:0px; top:150px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">진단명</caption>
			<input id="input21" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para12" style="left:102px; top:151px; width:438px; height:19px; "/>
			<caption id="caption22" class="cell_1" style="left:0px; top:125px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">연령/성별</caption>
			<caption id="caption23" class="cell_1" style="left:270px; top:125px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">채혈일</caption>
			<input id="input19" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para9" style="left:102px; top:126px; width:43px; height:19px; "/>
			<line id="line18" class="line_3" style="x1:0px; y1:198px; x2:540px; y2:198px; "/>
			<caption id="caption26" class="cell_1" style="left:0px; top:225px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">가족력</caption>
			<select id="checkbox1" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para15" overflow="visible" appearance="full" style="left:100px; top:229px; width:60px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>유</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox2" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para16" overflow="visible" appearance="full" style="left:160px; top:229px; width:60px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>무</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox3" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para17" overflow="visible" appearance="full" style="left:215px; top:229px; width:60px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>모름</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<input id="input4" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para13" style="left:102px; top:176px; width:438px; height:19px; "/>
			<caption id="caption9" class="cell_1" style="left:0px; top:175px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">주요증상</caption>
			<input id="input5" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para14" style="left:102px; top:201px; width:438px; height:19px; "/>
			<caption id="caption10" class="cell_1" style="left:0px; top:200px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">임상검사결과</caption>
			<caption id="caption11" class="cell_1" style="left:0px; top:355px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">의뢰검사명</caption>
			<line id="line13" class="line_3" style="x1:0px; y1:378px; x2:540px; y2:378px; "/>
			<select id="checkbox4" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para19" overflow="visible" appearance="full" style="left:100px; top:359px; width:160px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>Chromosome Analysis</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox5" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para20" overflow="visible" appearance="full" style="left:260px; top:359px; width:120px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>FISH Analysis</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox6" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para21" overflow="visible" appearance="full" style="left:380px; top:359px; width:120px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>DNA Diagnosis</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<caption id="caption12" class="cell_1" style="left:0px; top:380px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">구체적인 검사명</caption>
			<input id="input6" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para22" style="left:102px; top:381px; width:438px; height:19px; "/>
			<line id="line14" class="line_3" style="x1:0px; y1:403px; x2:540px; y2:403px; "/>
			<line id="line15" class="line_3" style="x1:0px; y1:453px; x2:540px; y2:453px; "/>
			<caption id="caption13" class="cell_1" style="left:0px; top:405px; width:100px; height:48px; text-align:left; vertical-align:middle; background-color:#99ccff; ">검체종류</caption>
			<select id="checkbox8" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para28" overflow="visible" appearance="full" style="left:100px; top:434px; width:115px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>Skin fibroblast</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox9" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para23" overflow="visible" appearance="full" style="left:100px; top:409px; width:55px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>Blood</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select1 id="radio1" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para10" appearance="full" cellspacing="20" cols="2" overflow="visible" style="left:160px; top:125px; width:105px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>남</label>
						<value>남</value>
					</item>
					<item>
						<label>여</label>
						<value>여</value>
					</item>
				</choices>
			</select1>
			<input id="input10" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para11" class="input_s_essential" inputtype="date" style="left:372px; top:126px; width:165px; height:19px; font-weight:normal; "/>
			<select id="checkbox7" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para24" overflow="visible" appearance="full" style="left:155px; top:409px; width:100px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>Bone marrow</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox15" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para25" overflow="visible" appearance="full" style="left:255px; top:409px; width:100px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>Amniotic Fluid</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox16" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para26" overflow="visible" appearance="full" style="left:355px; top:409px; width:100px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>Chorionic villi</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox17" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para27" overflow="visible" appearance="full" style="left:455px; top:409px; width:85px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>Cord Blood</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox10" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para29" overflow="visible" appearance="full" style="left:215px; top:434px; width:100px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>Lymph node</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox11" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para30" overflow="visible" appearance="full" style="left:315px; top:434px; width:85px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>AutoPsy</label>
						<value>V</value>
					</item>
				</choices>
			</select>
			<select id="checkbox12" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para31" overflow="visible" appearance="full" style="left:400px; top:434px; width:85px; height:20px; border-style:none; ">
				<choices>
					<item>
						<label>Other</label>
						<value>V</value>
					</item>
				</choices>
			</select>
		</group>
		<group id="group3" style="left:0px; top:465px; width:545px; height:27px; ">
			<line id="line2" class="line_2" style="x1:0px; y1:0px; x2:490px; y2:0px; "/>
			<button id="btn_close" class="btn4_letter2" style="left:489px; top:5px; width:56px; height:22px; ">
				<caption>닫기</caption>
				<script type="javascript" ev:event="DOMActivate">
					<![CDATA[
						fSetClose();
					]]>
				</script>
			</button>
			<button id="btn_save" class="btn4_letter2" style="left:430px; top:5px; width:56px; height:22px; ">
				<caption>확인</caption>
				<script type="javascript" ev:event="DOMActivate">
					<![CDATA[
						fExeClinicSave();
					]]>
				</script>
			</button>
		</group>
	</xhtml:body>
</xhtml:html>