消化内科入院记录

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1、医院消化内科入院记录（一）姓名男女年龄科别病区床号住院号民族婚否职业住址出生地入院日期记录时间病史陈述者、可靠程度主诉：_______________________________________________________________________________________现病史：_______________________________________________________________________________________________________

2、______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3、______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4、____________________________________________________________________________________________________________________________________________________________________________仍需治疗的合并疾病情况：______________________________________________________________________

5、______________________________________________________________________________________________________________________________________________________________________既往史：一般健康状况：良好一般较差疾病史：无有_________________________________________________________________

6、______________________________________________________________________________________________________________________________________________________________________________________传染病史:无有_________________________________________________________________

7、______预防接种史:无有不祥预防接种疫苗：______________________________________________________________________手术外伤史：手术：无有名称及时间：_____________________________________________外伤：无有外伤情况及时间：_________________________________________输血史：无有输血反应:无有________________________________

8、__________________食物或药物过敏史：无有不祥过敏药品和食物名称：_____________________________________________________________________个人史：出生地：________________经常居留地_________________寄生虫疫水接触史_____________________第页消化内科入院记录（二）姓名科别病区床号住院号吸烟史：无有：平均___支