英文病历模版.docx
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英文病历模版
Name:
______________Sex:
__________Age:
___________Nation:
___________
BirthPlace:
________________________________MaritalStatus:
____________
Work-organization&Occupation:
_______________________________________
LivingAddress&Tel:
_________________________________________________
Dateofadmission:
_______Dateofhistorytaken:
_______Informant:
__________
ChiefComplaint:
___________________________________________________
HistoryofPresentIllness:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PastHistory:
GeneralHealthStatus:
1.good2.moderate3.poor
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:
1.None2.Yes
Traumadetails:
_________________________________________
Bloodtransfusionhistory:
1.None2.Yes（1.Wholeblood2.Plasma3.Ingredienttransfusion）
Bloodtype:
____________Transfusiontime:
___________
Transfusionreaction
1.None2.Yes
Clinicmanifestation:
_____________________________
Allergichistory:
1.None2.Yes3.Notclear
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:
________3.deceasedcause:
___________________
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.positive3pulsive4.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:
1.normal2.abnormal（description:
______________________）
Others:
___________________________________________________________
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________________
Percussion:
1.resonance2.Hyperresonance&location_____________3Flatness&location_________________________________
4.dullness&location:
________
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