英文病历模版文档格式.docx

英文病历模版文档格式.docx

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Diseasehistory:

（ifany,pleasewritedownthedateofonset,briefdiagnosticandtherapeuticcourse,andtheresults.）

Respiratorysystem:

1.None2.Repeatedpharyngealpain3.chroniccough4.expectoration:

5.Hemoptysis6.asthma7.dyspnea8.chestpain

_______________________________________________________________

Circulatorysystem:

1.None2.Palpitation3.exertionaldyspnea4..cyanosis5.hemoptysis

6.Edemaoflowerextremities7.chestpain8.syncope9.hypertension

Digestivesystem:

1.None2.Anorexia3.dysphagia4.sourregurgitation5.eructation6.nausea7.Emesis8.melena9.abdominalpain10.diarrhea11.hematemesis12.Hematochezia13.jaundice

Urinarysystem:

1.None2.Lumbarpain3.urinaryfrequency4.urinaryurgency5.dysuria6.oliguria7.polyuria8.retentionofurine9.incontinenceofurine10.hematuria11.Pyuria12.nocturia13.puffyface

Hematopoieticsystem:

1.None2.Fatigue3.dizziness4.gingivalhemorrhage5.epistaxis6.subcutaneoushemorrhage

Metabolicandendocrinesystem:

1.None2.Bulimia3.anorexia4.hotintolerance5.coldintolerance

6.hyperhidrosis7.Polydipsia8.amenorrhea

9.tremorofhands10.characterchange11.Markedobesity12.markedemaciation13.hirsutism14.alopecia

15.Hyperpigmentation16.sexualfunctionchange

Neurologicalsystem:

1.None2.Dizziness3.headache4.paresthesia5.hypomnesis6.Visualdisturbance7.Insomnia8.somnolence9.syncope10.convulsion11.Disturbanceofconsciousness12.paralysis13.vertigo

Reproductivesystem:

1.None2.others

Musculoskeletalsystem:

1.None2.Migratingarthralgia3.arthralgia4.artrcocele5.arthremia

6.Dysarthrosis7.myalgia8.muscularatrophy

InfectiousDisease:

1.None2.Typhoidfever3.Dysentery4.Malaria4.Schistosomiasis4.Leptospirosis7.Tuberculosis8.Epidemichemorrhagicfever9.others

Vaccineinoculation:

1.None2.Yes3.Notclear

Vaccinedetail__________________________________________

Traumaand/oroperationhistory:

Operations:

1.None2.Yes

Operationdetails:

_______________________________________

Traumas:

Traumadetails:

_________________________________________

Bloodtransfusionhistory:

1.None2.Yes（1.Wholeblood2.Plasma3.Ingredienttransfusion）

Bloodtype:

____________Transfusiontime:

___________

Transfusionreaction

1.None2.Yes

Clinicmanifestation:

_____________________________

Allergichistory:

allergen:

________________________________________________

clinicalmanifestation:

_____________________________________

Personalhistory:

Customlivingaddress:

____________________________________________

Residenthistoryinendemicdiseasearea:

Smoking:

1.No2.Yes

Average___piecesperday;

about___years

Giving-up1.No2.Yes（Time:

_______________________）

Drinking:

1.No2.Yes

Average___gramsperday;

about___years

Giving-up1.No2.Yes（Time:

________________________）

Drugabuse:

1.No2.Yes

Drugnames:

Maritalandobstetricalhistory:

Marriedage:

__________yearsoldPregnancy___________times

Labor_______________times

（1.Naturallabor:

_______times2.Operativelabor:

________times

3.Naturalabortion:

______times4.Artificialabortion:

_______times

5.Prematurelabor:

__________times6.stillbirth__________times）

HealthstatusoftheMate:

1.Well2.Notfine

Details:

_______________________________________________

Menstrualhistory:

Menarchalage:

_______Duration______dayInterval____days

Lastmenstrualperiod:

____________Menopausalage:

____yearsold

Amountofflow:

1.small2.moderate3.large

Dysmenorrheal:

1.presence2.absenceMenstrualirregularity1.No2.Yes

Familyhistory:

（especiallypayattentiontotheinfectiousandhereditarydiseaserelatedtothepresentillness）

Father:

1.healthy2.ill:

________3.deceasedcause:

___________________

Mother:

1.healthy2.ill:

Others:

________________________________________________________

Theanteriorstatementwasagreedbytheinformant.

Signatureofinformant:

Datetime:

PhysicalExamination

Vitalsigns:

Temperature:

______0CBloodpressure:

_______/_______mmHg

Pulse:

_____bpm（1.regular2.irregular_____________________________）

Respiration:

___bpm（1.regular2.irregular____________________________）

Generalconditions:

Development:

1.Normal2.Hypoplasia3.Hyperplasia

Nutrition:

1.good2.moderate3.poor4.cachexia

Facialexpression:

1.normal2.acute3.chronicother_____________________

Habitus:

1.asthenictype2.sthenictype3.ortho-thenictype

Position:

1.active2.positivepulsive4.other_______________________

Consciousness:

1.clear2.somnolence3.confusion4.stupor5.slightcoma6.mediatecoma7.deepcoma8.delirium

Cooperation:

1Yes2.NoGait:

1.normal2.abnormal______

Skinandmucosa:

Color:

1.normal2.pale3.redness4.cyanosis5.jaundice6.pigmentation

Skineruption:

1.No2.Yes（type:

__________distribution:

__________________）

Subcutaneousbleeding:

1.no2.yes（type:

_______distribution:

______________）

Edema:

1.no2.yes（locationanddegree________________________________）

Hair:

1.normal2.abnormal（details_____________________________________）

Temperatureandmoisture:

normalcoldwarmdrymoistdehydration

Liverpalmar:

1.no2.yesSpiderangioma（location:

________________）

Others:

__________________________________________________________

Lymphnodes:

enlargementofsuperficiallymphnode:

1.no2.yes

Description:

________________________________________________

Head:

Skullsize:

1.normal2.abnormal（description:

____________________________）

Skullshape:

1.normal2.abnormal（description:

___________________________）

Hairdistribution:

______________________）

___________________________________________________________

Eye:

exophthalmos:

___________eyelid:

____________conjunctiva:

__________sclera:

________________Cornea:

_______________________

Pupil:

1.equallyroundandinsize2.unequal（R______mmL_______mm）

Pupilreflex:

1.normal2.delayed（R___sL___s）3.absent（R___L___）others:

______________________________________________________

Ear:

Auricle1.normal2.desformation（description:

Dischargeofexternalauditorycanal:

1.no2.yes（1.left2.rightquality:

_____）

Mastoidtenderness1.no2.yes（1.left2.rightquality:

__________________）Disturbanceofauditoryacuity:

1.no2.yes（1.left2.rightdescription:

_______）

Nose:

Flaringofalaenasi:

1.no2.yesStuffydischarge1.no2.yes（quality______）

Tendernessoverparanasalsinuses:

1.no2.yes（location:

_______________）

Mouth:

Lip______________Mucosa_____________Tongue________________

Teeth:

1.normal2.Agomphiasis3.Eurodontia4.others:

____________________

Gum:

1.normal2.abnormal（Description____________________________）Tonsil:

___________________________Pharynx:

_____________________

Sound:

1.normal2.hoarseness3.others:

_____________________________

Neck:

Neckrigidity1.no2.yes（______________transversfingers）

Carotidartery:

1.normalpulsation2.increasedpulsation3.markeddistention

Trachealocation:

1.middle2.deviation（1.leftward_______2.rightward______）

Hepatojugularveinreflux:

1.negative2.positive

Thyroid:

1.normal2.enlarged_______3.bruit（1.no2.yes________________）

Chest:

Chestwall:

1.normal2.barrelchest3.prominenceorretraction:

（left________right_________Precordialprominence__________）

Percussionpainoversternum1.No2.Yes

Breast:

1.Normal2.abnormal_______________________________________

Lung:

Inspection:

respiratorymovement1.normal2.abnormal_____________

Palpation:

vocaltactilefremitus:

1.normal2.abnormal_______________pleuralrubbingsensation:

1.no2.yes______________________

Subcutaneouscrepitussensation:

1.no2.yes________________