英文病历模版

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1、Division:__________Ward:__________Bed:_________CaseNo.___________Name:______________Sex:__________Age:___________Nation:___________BirthPlace:________________________________MaritalStatus:____________Work-organization&Occupation:_______________________________________Livi

2、ngAddress&Tel:_________________________________________________Dateofadmission:_______Dateofhistorytaken:_______Informant:__________ChiefComplaint:___________________________________________________HistoryofPresentIllness:__________________________________________________

3、________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4、________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5、________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PastHistory:GeneralHealthStatus:1.good2.

6、moderate3.poorDiseasehistory:(ifany,pleasewritedownthedateofonset,briefdiagnosticVIIIDivision:__________Ward:__________Bed:_________CaseNo.___________andtherapeuticcourse,andtheresults.)Respiratorysystem:1.None2.Repeatedpharyngealpain3.chroniccough4.expectoration:5.Hemopt

7、ysis6.asthma7.dyspnea8.chestpain_______________________________________________________________Circulatorysystem:1.None2.Palpitation3.exertionaldyspnea4..cyanosis5.hemoptysis6.Edemaoflowerextremities7.chestpain8.syncope9.hypertension_______________________________________

8、________________________Digestivesystem:1.None2.Anorexia3.dysphagia4.sourregurgitation5.eructati