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1、学 海 无 涯 I Name: _ Sex: _ Age: _ Nation: _ Birth Place: _ Marital Status:_ Work-organization about_years Giving-up 1.No 2.Yes (Time:_) Drinking: 1.No 2.Yes Average _grams per day; about _years Giving-up 1.No 2.Yes(Time:_) Drug abuse:1.No 2.Yes Drug names:_ _ Marital and obstetrical history: Married a
2、ge: _years old Pregnancy _times Labor _times (1.Natural labor: _times 2.Operative labor: _times 3.Natural abortion: _times 4.Artificial abortion: _times 5.Premature labor:_times 6.stillbirth_times) Health status of the Mate: 学 海 无 涯 IV 1.Well 2.Not fine Details: _ Menstrual history: Menarchal age: _
3、 Duration _day Interval _days Last menstrual period: _ Menopausal age: _years old Amount of flow: 1.small 2. moderate 3. large Dysmenorrheal: 1. presence 2.absence Menstrual irregularity 1. No 2.Yes Family history: (especially pay attention to the infectious and hereditary disease related to the pre
4、sent illness) Father: 1.healthy 2.ill:_ 3.deceased cause: _ Mother:1.healthy 2.ill:_ 3.deceased cause: _ Others: _ The anterior statement was agreed by the informant. Signature of informant: Datetime: Physical Examination Vital signs: Temperature:_0C Blood pressure:_/_mmHg Pulse: _ bpm (1.regular 2.
5、irregular_) Respiration: _bpm (1.regular 2.irregular_) General conditions: Development: 1.Normal 2.Hypoplasia 3.Hyperplasia Nutrition: 1.good 2.moderate 3.poor 4.cachexia Facial expression: 1.normal 2.acute 3.chronic other_ Habitus: 1.asthenic type 2.sthenic type 3.ortho-thenic type Position: 1.acti
6、ve 2.positive pulsive 4.other_ Consciousness: 1.clear 2.somnolence 3.confusion 4.stupor 5.slight coma 6.mediate coma 7.deep coma 8.delirium Cooperation: 1Yes 2.No Gait: 1.normal 2.abnormal_ Skin and mucosa: Color: 1.normal 2.pale 3.redness 4.cyanosis 5.jaundice 6.pigmentation Skin eruption:1.No 2.Ye
7、s( type: _distribution:_) Subcutaneous bleeding: 1.no 2.yes (type:_distribution:_) Edema:1. no 2.yes ( location and degree_) Hair: 1.normal 2.abnormal(details_) Temperature and moisture: normal cold warm dry moist dehydration Liver palmar : 1.no 2.yes Spider angioma (location:_) Others: _ 学 海 无 涯 V
8、Lymph nodes: enlargement of superficial lymph node: 1. no 2.yes Description: _ Head: Skull size:1.normal 2.abnormal (description:_) Skull shape:1.normal 2.abnormal(description:_) Hair distribution :1.normal 2.abnormal(description:_) Others:_ Eye: exophthalmos:_eyelid:_conjunctiva:_ sclera:_Cornea:_
9、Pupil: 1.equally round and in size 2.unequal (R_mm L_mm) Pupil reflex: 1.normal 2.delayed (R_s L_s ) 3.absent (R_L_) others:_ Ear: Auricle 1.normal 2.desformation (description:_) Discharge of external auditory canal:1.no 2.yes (1.left 2.right quality:_) Mastoid tenderness 1.no 2.yes (1.left 2.right
10、quality:_) Disturbance of auditory acuity:1.no 2.yes(1.left 2.right description:_) Nose: Flaring of alae nasi :1.no 2.yes Stuffy discharge 1.no 2.yes(quality_) Tenderness over paranasal sinuses:1.no 2.yes (location:_) Mouth: Lip_Mucosa_Tongue_ Teeth:1.normal 2. Agomphiasis 3. Eurodontia 4.others:_ G
11、um :1.normal 2.abnormal (Description_) Tonsil:_Pharynx:_ Sound: 1.normal 2.hoarseness 3.others:_ Neck: Neck rigidity 1.no 2.yes (_transvers fingers) Carotid artery: 1.normal pulsation 2.increased pulsation 3.marked distention Trachea location: 1.middle 2.deviation (1.leftward_2.rightward_) Hepatojugular vein reflux: 1. negative 2.positive Thyroid: 1.normal 2.enlarged _ 3.bruit (1.no 2.yes _) Chest: Chest wall: 1.normal 2.barrel chest 3.prominence or retraction: ( lef
