内科英文病历模板.doc

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1、......HUAZHONGUNIVERSITYOFSCIENCEANDTECHNOLOGYTONGJIMEDICALCOLLEGEACCESSORYTONGJIHOSPITALHospitalizationRecordsforNone-operationDivisionDivision:__________Ward:__________Bed:_________CaseNo.___________Name:______________Sex:__________Age:___________Nation:__

2、_________BirthPlace:________________________________MaritalStatus:____________Work-organization&Occupation:_______________________________________LivingAddress&Tel:_________________________________________________Dateofadmission:_______Dateofhistorytaken:___

3、____Informant:__________ChiefComplaint:___________________________________________________HistoryofPresentIllness:________________________________________________________________________________________________________________________________________________

4、__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5、__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6、______________________________________________________________________________________________________________________________________________________________________学习好帮手......PastHistory:GeneralHealthStatus:1.good2.moderate3.poorDiseasehistory:(ifany,pleas

7、ewritedownthedateofonset,briefdiagnosticandtherapeuticcourse,andtheresults.)Respiratorysystem:1.None2.Repeatedpharyngealpain3.chroniccough4.expectoration:5.Hemoptysis6.asthma7.dyspnea8.chestpain_______________________________________________________________C

8、irculatorysystem:1.None2.Palpitation3.exertionaldyspnea4..cyanosis5.hemoptysis6.Edemaoflowerextremities7.chestpain8.syncope9.hypertension_________________________________________________________