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ID:42369997
大小:325.02 KB
页数:4页
时间:2019-09-13
《英文病历书写模板 medical-history-questionnaire》由会员上传分享,免费在线阅读,更多相关内容在应用文档-天天文库。
1、MedicalHistoryQuestionnaireNAME:_________________________________________TODAY’SDATE:__________________FirstMiddleInitialLastDATEOFBIRTH:__________________Thisquestionnairewasdesignedtoprovideimportantfactsregardingthehistoryofyourpainorcondition.Theinformationyouprovidewillassistinrea
2、chingdiagnosisanddeterminingthesourceofyourproblem.Pleasetakeyourtimeandanswereachquestionascompletelyandhonestlyaspossible.Pleasesigneverypage.LISTANYMEDICATIONS/SUBSTANCESWHICHHAVECAUSEDANALLERGICREACTION:YNAntibioticsYNLatexYNSedativesYNAspirinYNLocalanestheticsYNSleepingpillsYNBarb
3、ituratesYNMetalsYNSulfadrugsYNCodeineYNPenicillinYNYNIodineYNPlasticYNOther_______________________________________________________________________LISTANYMEDICATIONSCURRENTLYBEINGTAKEN:MedicationDosage/FrequencyReason______________________________________________________________________
4、______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5、________________MEDICALHISTORY:(Pleaseindicatedatesonitemsmarkedcurrentorpast)MedicalConditionNeverCurrentPastMedicalConditionNeverCurrentPastAcidrefluxInsomniaAdenoidsRemovedIntestinaldisorderAnemiaJawjointsurgeryArteriosclerosisKidneyproblemsArthritisliverdiseaseAsthmaLowenergyAutoim
6、munedisorderMeniere'sdiseaseBleedingeasilyMenstrualcrampsBloodpressure-HighMultiplesclerosisBloodpressure-LowMuscleachesBotoxMuscleshaking(tremors)BruisingeasilyMusclespasmsorcrampsCancerMusculardystrophyChemotherapyNasalallergiesChroniccoughNeedingextrapillowtohelpChronicfatiguebreath
7、ingatnightChronicpainNervoussystemirritabilityColdhandsandfeetNervousnessCOPDNeuralgiaDepressionNumbnessoffingersDiabetesOsteoarthritisDifficultyconcentratingOsteoporosisPatientSignature______________________________Date_________________________Page1MedicalconditionNeverCurrentPastMe
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