세포유전학검사 의뢰서 등록

유전질환검사의뢰서(서울대학병원) 환자성명 성별/생년월일 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; "/>
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			<line id="line8" class="line_3" style="x1:0px; y1:173px; x2:540px; y2:173px; "/>
			<line id="line9" class="line_3" style="x1:0px; y1:198px; x2:540px; y2:198px; "/>
			<line id="line10" class="line_3" style="x1:0px; y1:273px; x2:540px; y2:273px; "/>
			<line id="line16" class="line_1" style="x1:0px; y1:340px; x2:540px; y2:340px; "/>
			<caption id="caption18" class="cell_1" style="left:270px; top:50px; width:100px; height:23px; text-align:left; vertical-align:middle; ">의뢰병원명</caption>
			<caption id="caption19" class="cell_1" style="left:270px; top:25px; width:100px; height:23px; text-align:left; vertical-align:middle; ">환자번호</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:167px; top:51px; width:98px; 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; ">진료과</caption>
			<input id="input14" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para6" 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; ">검체채취일자</caption>
			<caption id="caption21" class="cell_1" style="left:0px; top:100px; width:270px; height:23px; text-align:left; vertical-align:middle; ">외국인인 경우 국적 및 민족을 기록하여주십시오</caption>
			<caption id="caption4" class="cell_1" style="left:0px; top:125px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">의뢰검사명</caption>
			<input id="input17" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para10" style="left:102px; top:126px; width:438px; height:19px; "/>
			<line id="line17" class="line_3" style="x1:0px; y1:223px; x2:540px; y2:223px; "/>
			<caption id="caption8" class="cell_1" style="left:0px; top:200px; width:126px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">임상진단 주요증상 1)</caption>
			<input id="input21" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para14" style="left:127px; top:201px; width:413px; height:19px; "/>
			<caption id="caption22" class="cell_1" style="left:0px; top:150px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">의뢰의사(성명)</caption>
			<caption id="caption23" class="cell_1" style="left:270px; top:150px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">의뢰의사(전화)</caption>
			<input id="input19" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para11" style="left:102px; top:151px; width:163px; height:19px; "/>
			<input id="input22" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para12" style="left:372px; top:151px; width:168px; height:19px; "/>
			<line id="line18" class="line_3" style="x1:0px; y1:248px; x2:540px; y2:248px; "/>
			<input id="input4" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para16" style="left:102px; top:251px; width:438px; height:19px; "/>
			<caption id="caption9" class="cell_1" style="left:0px; top:250px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">Age of onset</caption>
			<select1 id="radio2" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para3" appearance="full" cellspacing="1" cols="2" overflow="visible" style="left:102px; top:50px; width:63px; 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="input2" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para5" style="left:372px; top:51px; width:168px; height:19px; "/>
			<input id="input3" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para7" class="input_s_essential" inputtype="date" style="left:372px; top:76px; width:168px; height:19px; font-weight:normal; "/>
			<caption id="caption3" style="left:285px; top:101px; width:30px; height:20px; ">국적</caption>
			<input id="input10" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para8" style="left:317px; top:101px; width:88px; height:19px; "/>
			<input id="input11" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para9" style="left:452px; top:101px; width:88px; height:19px; "/>
			<caption id="caption14" style="left:410px; top:101px; width:40px; height:20px; ">, 민족</caption>
			<caption id="caption6" class="cell_1" style="left:0px; top:175px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">채혈자(성명)</caption>
			<input id="input16" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para13" style="left:102px; top:176px; width:163px; height:19px; "/>
			<input id="input15" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para15" style="left:127px; top:226px; width:413px; height:19px; "/>
			<caption id="caption7" class="cell_1" style="left:0px; top:225px; width:126px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">임상진단 주요증상 2)</caption>
			<caption id="caption15" style="left:0px; top:296px; width:485px; height:20px; ">- 남자 □, 여자○, 환자남자 ■, 환자여자 □, 형제는 나이가 많은 순서로 왼쪽부터 그림.</caption>
			<caption id="caption16" style="left:0px; top:321px; width:515px; height:20px; ">- 각 사람 밑에 이름과 연령(사망자는 사망시 나이)을 기록하시고, 채혈한 환자를 표시하십시오.</caption>
			<line id="line11" class="line_1" style="x1:0px; y1:450px; x2:540px; y2:450px; "/>
			<caption id="caption10" class="tit_2" style="left:0px; top:436px; width:157px; height:14px; ">검체기록</caption>
			<input id="input5" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para18" style="left:0px; top:481px; width:100px; height:19px; "/>
			<caption id="caption11" class="cell_1" style="left:0px; top:455px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">환자이름</caption>
			<caption id="caption12" class="cell_1" style="left:102px; top:455px; width:100px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">생년월일</caption>
			<input id="input6" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para19" class="input_s_essential" inputtype="date" style="left:102px; top:480px; width:100px; height:19px; font-weight:normal; "/>
			<line id="line12" class="line_3" style="x1:0px; y1:501px; x2:540px; y2:501px; "/>
			<caption id="caption13" class="cell_1" style="left:204px; top:455px; width:145px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">Proband와 관계</caption>
			<input id="input7" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para20" style="left:204px; top:481px; width:145px; height:19px; "/>
			<caption id="caption24" class="cell_1" style="left:351px; top:455px; width:189px; height:23px; text-align:left; vertical-align:middle; background-color:#99ccff; ">Pedigree 중 위치 표시</caption>
			<input id="input8" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para21" style="left:351px; top:481px; width:189px; height:19px; "/>
			<input id="input9" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para24" style="left:204px; top:506px; width:145px; height:19px; "/>
			<input id="input18" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para25" style="left:351px; top:506px; width:189px; height:19px; "/>
			<line id="line13" class="line_3" style="x1:0px; y1:526px; x2:540px; y2:526px; "/>
			<input id="input20" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para22" style="left:0px; top:506px; width:100px; height:19px; "/>
			<input id="input23" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para23" class="input_s_essential" inputtype="date" style="left:102px; top:505px; width:100px; height:19px; font-weight:normal; "/>
			<input id="input24" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para28" style="left:204px; top:531px; width:145px; height:19px; "/>
			<input id="input25" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para26" style="left:0px; top:531px; width:100px; height:19px; "/>
			<line id="line14" class="line_3" style="x1:0px; y1:551px; x2:540px; y2:551px; "/>
			<input id="input26" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para27" class="input_s_essential" inputtype="date" style="left:102px; top:530px; width:100px; height:19px; font-weight:normal; "/>
			<input id="input27" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para29" style="left:351px; top:531px; width:189px; height:19px; "/>
			<line id="line15" class="line_3" style="x1:0px; y1:576px; x2:540px; y2:576px; "/>
			<input id="input28" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para32" style="left:204px; top:556px; width:145px; height:19px; "/>
			<input id="input29" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para30" style="left:0px; top:556px; width:100px; height:19px; "/>
			<input id="input30" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para31" class="input_s_essential" inputtype="date" style="left:102px; top:555px; width:100px; height:19px; font-weight:normal; "/>
			<input id="input31" ref="/root/main/reqfrm/reqfrmtbl/reqfrminfo/inptitem01/para33" style="left:351px; top:556px; width:189px; height:19px; "/>
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		<group id="group3" style="left:0px; top:595px; 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>