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英文病历模版

作者：高考题库网
来源：https://www.bjmy2z.cn/gaokao
2021-02-13 04:34
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2021年2月13日发(作者：positioning)


Division: __________ Ward: __________ Bed: _________ Case No. ___________




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.)




I


Division: __________ Ward: __________ Bed: _________ Case No. ___________



Respiratory system:


1. None



ed pharyngeal pain c cough oration:



5. Hemoptysis





a



pain


__________ __________________________________________________ ___


Circulatory system:





ation



onal dyspnea



4..cyanosis



ysis



of lower extremities pain e ension



__________________ _____________________________________________


Digestive system:






ia



gia



regurgitation



tion













nal pain ea



mesis chezia



ce



_ __________________________________________________ ____________


Urinary system:






pain y frequency y urgency a


ia ia ion of urine inence of urine


ria ia face



__ __________________________________________________ ___________


Hematopoietic system:






e ess al hemorrhage xis


aneous hemorrhage


________________________________________________ _______________


Metabolic and endocrine system:







a



ia



intolerance



intolerance



idrosis



psia



rhea



of hands



ter change




obesity


emaciation



ism






ia



igmentation




function change


________________________________ _______________________________


Neurological system:






ess



he



hesia



esis









6. Visual disturbance



ia



ence








e



sion



bance of consciousness


sis



13.



vertigo



___________________________ ____________________________________


Reproductive system:






___ __________________________________________________ __________



Musculoskeletal system:






ing arthralgia



lgia



cele



mia



hrosis



a







ar atrophy



___________________________________________ ____________________


Infectious Disease:




II


Division: __________ Ward: __________ Bed: _________ Case No. ___________






d fever




ery




a osomiasis





pirosis




ulosis



ic hemorrhagic fever






_______________ ________________________________________________


Vaccine inoculation:









clear


Vaccine detail __________________________________________


Trauma and/or operation history:





Operations:















Operation details:_______________________________________





Traumas:















Trauma details:_________________________________________


Blood transfusion history:





( blood





ient transfusion)











Blood type:____________ Transfusion time:___________










Transfusion reaction





























Clinic manifestation:_____________________________


Allergic history:









clear

< br>allergen:______________________________________ __________


clinical manifestation:_____ ________________________________



Personal history:


Custom living address:


________________________ ____________________


Resident history in endemic disease area:


_____________________________


Smoking:






Average ___pieces per day;



about___years



Giving-up



(Time:_______________________)


Drinking:





Average ___grams per day;



about ___years



Giving-up



(Time:________________________)


Drug abuse:

















Drug names:_______________________________________


___________________________________________ ____________________



Marital and obstetrical history:


Married age:


__________years old





Pregnancy


___________times




Labor


_______________times




III


Division: __________ Ward: __________ Bed: _________ Case No. ___________



(l labor: _______times




ive labor: ________times



l abortion: ______times



cial abortion: _______times



ure labor:__________times



irth__________times)







Health status of the Mate:












fine

















Details: _______________________________________________


Menstrual history:


Menarchal age:


_______




Duration


______day






Interval


____days


Last menstrual period:


____________




Menopausal age:


____years old


Amount of flow:






2. moderate



3. large





Dysmenorrheal:


1. presence e


Menstrual irregularity


1. No


Family history:


(especially pay attention to the infectious and hereditary disease


related to the present illness)



Father:


y



:________



ed cause: ___________________


Mother


:y



:________



ed cause: ___________________


Others:


____________________ ____________________________________




The anterior statement was agreed by the informant.

























Signature of informant:













Datetime:

















Physical




Examination


Vital signs:





Temperature:_


___ __


0


C











Blood pressure:


_______/_______mmHg



Pulse:


_____ bpm (r




lar_____________________________)


Respiration:


___bpm (r lar____________________________)


General conditions:


Development:




asia



lasia




Nutrition


:



te





ia


Facial expression:


c other_____________________


Habitus:


ic type



c type



-thenic type


Position:


ve sive _______________________



Consciousness:




ence



ion



coma


e coma



coma



um




Cooperation


:



1Yes








Gait:



al______



Skin and mucosa:


Color:


s is ce tation



IV

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-


-


-


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