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[{"$nulls":11},"（様式A-2）"]
[]
["返書（かかりつけ医→地域）"]
[]
[null,null,"○○市町村　保健師　行き",null,null,"　　　　　　　　　保健師"]
[{"$nulls":3},"　　　栄養士",null,null,"　 　栄養士"]
[{"$nulls":6},"受診者氏名",{"$nulls":3},"　　　様"]
[]
[null,null,"診断名　　　"]
[]
[]
[]
[null,null,"今後について（必要に応じてご記入下さい）"]
[null,null,"【　　　　】1.栄養指導希望（自治体でも対応が可能です）"]
[]
[]
[]
[null,null,"【　　　　】2.専門医に紹介希望"]
[]
[]
[]
[]
[null,null,"【　　　　】3.その他"]
[]
[]
[]
[]
[]
[]
[null,null,"　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　※お手数ですが添付の封筒にて郵送をお願いします"]