英文病历模版.docx

Name: Sex: Age: Nati on: Birth Place: Marital Status: Work-orga ni zati on Occupati on: Living Address Tel: Date of admissi on: Date of history taken: Informant: Chief Complai nt: History of Prese nt Ill ness: Past History: General Health Status: 1. good 2.moderate 3.poor Disease history: (if any, please write downthe date of onset, brief diagnostic and therapeutic course, and the results.) Respiratory system: None 2.Repeated pharyngeal pain 3.chronic cough expectoration: Hemoptysis 6.asthma 7.dyspnea 8.chest pain Circulatory system: None 2.Palpitation 3.exertional dyspnea 4..cyanosis 5.hemoptysis Edema of lower extremities 7.chest pain 8.syncope 9.hypertension Digestive system: None 2.Anorexia 3.dysphagia 4.sour regurgitation 5.eructation 6.nausea 7.Emesis 8.melena 9.abdominal pain 10.diarrhea 11.hematemesis 12.Hematochezia 13.jaundice Urinary system: None 2.Lumbar pain 3.urinary frequency 4.urinary urgency 5.dysuria 6.oliguria 7.polyuria 8.retention of urine 9.incontinence of urine 10.hematuria 11.Pyuria 12.nocturia 13.puffy face Hematopoietic system: None 2.Fatigue 3.dizziness 4.gingival hemorrhage 5.epistaxis 6.subcutaneous hemorrhage Metabolic and endocrine system: 1.None 2.Bulimia 3.anorexia 4.hot intolerance 5.cold intolerance 6.hyperhidrosis 7.Polydipsia 8.amenorrhea 9.tremor of hands 10.character change 11.Marked obesity 12.marked emaciation 13.hirsutism 14.alopecia 15.Hyperpigmentation 16.sexual function change Neurological system: None 2.Dizziness 3.headache 4.paresthesia 5.hypomnesis 6. Visual disturbance 7.Insomnia 8.somnolence 9.syncope 10.convulsion 11.Disturbance of consciousness 12.paralysis 13. vertigo Reproductive system: 1.None 2.others Musculoskeletal system: 1.None 2.Migrating arthralgia 3.arthralgia 4.artrcocele 5.arthremia 6.Dysarthrosis 7.myalgia 8.muscular atrophy Infectious Disease: 1.None 2.Typhoid fever 3.Dysentery 4.Malaria 4.Schistosomiasis 4.Leptospirosis 7.Tuberculosis 8.Epidemic hemorrhagic fever 9.others Vaccine inoculation: 1