Division: __________ Ward: __________ Bed: _________ Ca No. ___________
Name: ______________ Sex: __________ Age: ___________ Nation: ___________
Birth Place: ________________________________ Marital Status:____________
Work-organization & Occupation: _______________________________________
Living Address & Tel手机网页: _________________________________________________
Date of admission: _______Date of history taken:_______ Informant:__________
Chief Complaint: ___________________________________________________
History of 四川辣椒油Prent Illness: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Past History:
General Health Status: 1.good 2.moderate 3.poor
过年期间Dia history: (if any, plea write down the date of ont, brief diagnostic and therapeutic cour, and the results.)数独高级解法
Respiratory system:
1. None 2.Repeated pharyngeal pain 3.chronic cough 4.expectoration:
5. Hemoptysis 6.asthma 7.dyspnea妇委会职责 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.naua 7.Emesis 8.melena 9.abdominal pain 10.diarrhea 11.hematemesis 12.Hematochezia 13.jaundice
_______________________________________________________________
Urinary system:
1.None 2.Lumbar pain 3.蒲坚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
_______________________________________________________________
Metabolic and endocrine system:
1.None 2.Bulimia 3.anorexia 4.hot intolerance 5.cold intolerance
6.hyperhidrosis 下心7.Polydipsia 8.amenorrhea
9.tremor of hands 10.character change 11.Marked obesity 12.marked emaciation 13.hirsutism 14.alopecia
15.Hyperpigmentation 16.趣味盎然xual function change
_______________________________________________________________
Neurological system:
1.None 2.Dizziness 3.headache 4.paresthesia 5.hypomnesis 6. Visual disturbance 7.Insomnia 8.somnolence 9.syncope 10.convulsion 11.Disturbance of consciousness 12.paralysis 13. vertigo
_______________________________________________________________
Reproductive system:
1.None 2.others
_______________________________________________________________
Musculoskeletal system:
1.None 2.Migrating arthralgia 3.arthralgia 4.artrcocele 5.arthremia
6.Dysarthrosis 7.myalgia 8.muscular atrophy
_______________________________________________________________
Infectious Dia:
1.None 2.Typhoid fever 3.Dyntery 4.Malaria 4.Schistosomiasis 4.Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever 9.others
_______________________________________________________________
Vaccine inoculation:
1.None 2.Yes 3.Not clear
Vaccine detail __________________________________________
Trauma and/or operation history:
Operations:
1.None 2.Yes
Operation details:_______________________________________
Traumas:
1.None 2.Yes
Trauma details:_________________________________________
Blood transfusion history:
1.None 2.Yes ( 1.Whole blood 2.Plasma 3.Ingredient transfusion)
Blood type:____________ Transfusion time:___________
Transfusion reaction
1.None 2.Yes
Clinic manifestation:_____________________________
Allergic history:
1.None 2.Yes 3.Not clear
allergen:________________________________________________
clinical manifestation:_____________________________________
