血液内科入院记录.doc

医 院 血液内科入院记录 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：_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 仍需治疗的合并疾病情况：_______________________________________________________________ ______________________________________________________________________________________ _______________________________________________________________________________________ 既往史：一般健康状况：良好 一般 较差 疾病史：无 有________________________________________________________________________ ________________________________________________________________________________________ _______________________________________________________________________________________ 传染病史:无 有_______________________________________________________________________ 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