英文病历模版

Divisio n: Ward: Bed: Case No.

Name: ______________ S ex: __________ Age: ___________ Natio n: __________ Birth Place: _______________________________ Marital Status: ___________ Work-orga nizatio n & Occupatio n: _____________________________________ Livi ng Address & Tel: ________________________________________________ Date of admissio n: ______ Date of history taken: _______ Informant: _________

Chief Complaint: ___________________________________________ History of Present Illness:

Past History:

General Health Status: 1.good 2.moderate 3.poor

Disease history :(if any, please write dow n the date of on set, brief diag no stic

and therapeutic course, and the results.)

Respiratory system:

1. None

2.Repeated pharyngeal pain

3.chronic cough

4.expectoration:

5. Hemoptysis

6.asthma

7.dysp nea

8.chest pa in

Circulatory system:

1.N one

2.Palpitatio n

3.exerti onal dysp nea

4..cya no sis

5.hemoptysis

6. Edema of lower extremities

7.chest pain

8.s yn cope

9.hyperte

nsion

Digestive system:

1.None

2.Anorexia

3.dysphagia

4.sour regurgitation

5.eructation

6.nausea

7.Emesis

8.melena

9.abdominal pain 10.diarrhea

11. hematemesis 12.Hematochezia 13.ja un dice

Urinary system:

1.N one

2.Lumbar pain

3.uri nary freque ncy

4.uri nary urge ncy

5.dysuria

6.oliguria

7.polyuria

8.retention of urine

9.ineontinence of urine

10.hematuria ll.Pyuria 12.n octuria 13.puffy face

Hematopoietic system:

1.N one

2.Fatigue

3.dizz in ess

4.gi ngival hemorrhage

5.epistaxis

6.subcuta neous hemorrhage

Metabolic and endocrine system:

1.None

2.Bulimia

3.anorexia

4.hot intoleranee

5.cold intoleranee

6.hyperhidrosis

7.Polydipsia

8.amenorrhea

9.tremor of hands 10.character cha nge II.Marked obesity

12. marked emaciati on 13.hirsutism 14.alopecia

15.Hyperpigme ntatio n 16.sexual fun cti on cha nge

Neurological system:

1.N one

2.Dizz in ess

3.headache

4.paresthesia

5.hypo mn esis

6. Visual disturbanee

7.lnsomnia

8.somnolence

9.s yn cope 10.c onv ulsi on II.Disturba nee of con scious ness

12.paralysis 13. vertigo

Reproductive system:

1.No ne

2.others

Musculoskeletal system:

1.None

2.Migrating arthralgia

3.arthralgia

4.artrcocele

5.arthremia

6.Dysarthrosis

7.myalgia

8.muscular atrophy