英文病历书写模板 medical-history-questionnaire

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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