英文住院病例模板.doc

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1、Division:__________Ward:__________Bed:_________CaseNo.___________Division:__________Ward:__________Bed:_________CaseNo.___________Name:______________Sex:__________Age:___________Nation:___________BirthPlace:________________________________MaritalStatus:____________Work

2、-organization&Occupation:_______________________________________LivingAddress&Tel:_________________________________________________Dateofadmission:_______Dateofhistorytaken:_______Informant:__________ChiefComplaint:___________________________________________________His

3、toryofPresentIllness:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4、_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5、_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6、________________________________________PastHistory:VIIIDivision:__________Ward:__________Bed:_________CaseNo.___________GeneralHealthStatus:1.good2.moderate3.poorDiseasehistory:(ifany,pleasewritedownthedateofonset,briefdiagnosticandtherapeuticcourse,andtheresults.)Res

7、piratorysystem:1.None2.Repeatedpharyngealpain3.chroniccough4.expectoration:5.Hemoptysis6.asthma7.dyspnea8.chestpain_______________________________________________________________Circulatorysystem:1.None2.Palpitation3.exertionaldyspnea4..cyanosis5.hemoptysis6.Edemaoflow

8、erextremities7.chestpain8.syncope9.hypertension_______________________________________________________________Digesti