英文病历模版
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Name: ______________ Sex: __________ Age: ___________ Nation: ___________
Birth Place: ________________________________ Marital
Status:____________
Work-organization & Occupation:
_______________________________________
Living Address & Tel:
_________________________________________________
Date of admission: _______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 down the date of onset, brief
diagnostic and therapeutic course, and the
results.)
Respiratory system:
1. None
2.Repeated pharyngeal pain
3.chronic cough
4.expectoration:
5. Hemoptysis
6.asthma
7.dyspnea
8.chest pain
____________________________________________________________ ___
Circulatory system:
1.None
2.Palpitation
3.exertional dyspnea
4..cyanosis
5.hemoptysis
6.Edema of lower extremities
7.chest pain
8.syncope
9.hypertension
_____________________________________________________
__________
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.jaundice
_____________________________________________________
__________
Urinary system:
1.None
2.Lumbar pain
3.urinary frequency
4.urinary urgency
5.dysuria
6.oliguria
7.polyuria
8.retention of urine
9.incontinence of urine 10.hematuria 11.Pyuria 12.nocturia
13.puffy face
_____________________________________________________
__________
Hematopoietic system:
1.None
2.Fatigue
3.dizziness
4.gingival hemorrhage
5.epistaxis
6.subcutaneous hemorrhage
_____________________________________________________
__________