英文病历模版

Division:__________Ward:__________Bed:_________CaseNo.___________IName:______________Sex:__________Age:___________Nation:___________BirthPlace:________________________________MaritalStatus:____________Work-organization&Occupation:_______________________________________LivingAddress&Tel:_________________________________________________Dateofadmission:_______Dateofhistorytaken:_______Informant:__________ChiefComplaint:___________________________________________________HistoryofPresentIllness:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PastHistory:GeneralHealthStatus:1.good2.moderate3.poorDiseasehistory:(ifany,pleasewritedownthedateofonset,briefdiagnosticandtherapeuticcourse,andtheresults.)Division:__________Ward:__________Bed:_________CaseNo.___________IIRespiratorysystem:1.None2.Repeatedpharyngealpain3.chroniccough4.expectoration:5.Hemoptysis6.asthma7.dyspnea8.chestpain_______________________________________________________________Circulatorysystem:1.None2.Palpitation3.exertionaldyspnea4..cyanosis5.hemoptysis6.Edemaoflowerextremities7.chestpain8.syncope9.hypertension_______________________________________________________________Digestivesystem:1.None2.Anorexia3.dysphagia4.sourregurgitation5.eructation6.nausea7.Emesis8.melena9.abdominalpain10.diarrhea11.hematemesis12.Hematochezia13.jaundice_______________________________________________________________Urinarysystem:1.None2.Lumbarpain3.urinaryfrequency4.urinaryurgency5.dysuria6.oliguria7.polyuria8.retentionofurine9.incontinenceofurine10.hematuria11.Pyuria12.nocturia13.puffyface_______________________________________________________________Hematopoieticsystem:1.None2.Fatigue3.dizziness4.gingivalhemorrhage5.epistaxis6.subcutaneoushemorrhage_______________________________________________________________Metabolicandendocrinesystem:1.None2.Bulimia3.anorexia4.hotintolerance5.coldintolerance6.hyperhidrosis7.Polydipsia8.amenorrhea9.tremorofhands10.characterchange11.Markedobesity12.markedemaciation13.hirsutism14.alopecia15.Hyperpigmentation16.sexualfunctionchange_______________________________________________________________Neurologicalsystem:1.None2.Dizziness3.headache4.paresthesia5.hypomnesis6.Visualdisturbance7.Insomnia8.somnolence9.syncope10.convulsion11.Disturbanceofconsciousness12.paralysis13.vertigo_______________________________________________________________Reproductivesystem:1.None2.others_______________________________________________________________Musculoskeletalsystem:1.None2.Migratingarthralgia3.arthralgia4.artrcocele5.arthremia6.Dysarthrosis7.myalgia8.muscularatrophy_______________________________________________________________InfectiousDisease:Division:__________Ward:__________Bed:_________CaseNo.___________III1.None2.Typhoidfever3.Dysentery4.Malaria4.Schistosomiasis4.Leptospirosis7.Tuberculosis8.Epidemichemorrhagicfever9.others_______________________________________________________________Vaccineinoculation:1.None2.Yes3.NotclearVaccinedetail__________________________________________Traumaand/oroperationhistory:Operations:1.None2.YesOperationdetails:_______________________________________Traumas:1.None2.YesTraumadetails:_________________________________________Bloodtransfusionhistory:1.None2.Yes(1.Wholeblood2.Plasma3.Ingredienttransfusion)Bloodtype:____________Transfusiontime:___________Transfusionreaction1.None2.YesClinicmanifestation:_____________________________Allergichistory:1.None2.Yes3.Notclearallergen:________________________________________________clinicalmanifestation:_____________________________________Personalhistory:Customlivingaddress:____________________________________________Residenthistoryinendemicdiseasearea:_____________________________Smoking:1.No2.YesAverage___piecesperday;about___yearsGiving-up1.No2.Yes(Time:_______________________)Drinking:1.No2.YesAverage___gramsperday;about___yearsGiving-up1.No2.Yes(Time:________________________)Drugabuse:1.No2.YesDrugnames:______________________________________________________________________________________________________Maritalandobstetricalhistory:Marriedage:__________yearsoldPregnancy___________timesLabor_______________timesDivision:__________Ward:__________Bed:_________CaseNo.___________IV(1.Naturallabor:_______times