姐妹机构转诊援助中心（SIRAC）评估表.PDF

Sister Institution Referral Assistance Center (SIRAC) Assessment Form 姐妹机构转诊援助中心（SIRAC）评估表 Please answer all of the following questions. It may be helpful for you to have your physician assist you in answering these questions. Please type or print clearly in English. 请回答以下所有问题。您可请您的医生协助您回答这些问题。请用英文清晰的书写或电 脑输入。 PATIENT INFORMATION Today’s date: ___________________________ 患者信息 填写日期： Patients name: (first) ___________________________________ (last) ___________________________________ 患者姓名： （名） （姓） Date of birth (D/M/Yr): ________________________________ Sex: ____________________________________ 出生日期 （日/月/年）： 性别： Birth city/State/Province: ___________________________________Birth country: ________________________ 出生地市/州/省： 出生国： Diagnosis: __________________________________________________________________________ 诊断： Date of diagnosis ___________________ Is this an original diagnosis or a recurrence? ______________________ 诊断日期 是初诊还是复诊？ If this is a recurrence, what is the date of the original diagnosis? ________________________________________ 若为复诊，初诊日期是什么时候？ How was the disease diagnosed? Surgical biopsy _______ Fine needle aspiration _____ Resection __________ 此病症是如何诊断的？ 手术活检 细针穿刺 切除 Has the disease spread to other organs? Yes ________ No ____________ 此病症是否已扩散到其他器官？ 是 否 If yes, please specify where ________________________ and the date it was discovered_________________ 若是，请注明何处 以及发现的日期 Is the patient ambulatory more than 50% of the day? Yes ______ No ______ 患者每天是否有50%以上的时间无需卧床？ 是