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1、-Name:_ Se*: _ Age: _ Nation:_ Birth Place: _Marital Status:_Work-organization & Occupation: _Living Address & Tel: _Date of admission:_Date of history taken:_ Informant:_Chief plaint:_History of PresentIllness:_Past History:General Health Status:1.good 2.moderate 3.poorDisease history: (if any, ple
2、ase write down the date of onset, brief diagnostic and therapeuticcourse, and the results.)Respiratory system:1. None 2.Repeatedpharyngealpain 3.chronic cough 4.e*pectoration:5. Hemoptysis 6.asthma 7.dyspnea 8.chest pain_Circulatory system:1.None 2.Palpitation 3.e*ertional dyspnea 4.cyanosis 5.hemop
3、tysis 6.Edema of lower e*tremities 7.chest pain 8.syncope 9.hypertension _Digestive system:1.None 2.Anore*ia 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:1.None 2.Lumbar pain 3.urinary
4、 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:1.None 2.Fatigue 3.dizziness 4.gingival hemorrhage 5.epista*is 6.subcutaneous hemorrhage _Metabolic and endocrine system:1.
5、None 2.Bulimia 3.anore*ia 4.hot intolerance 5.coldintolerance 6.hyperhidrosis7.Polydipsia 8.amenorrhea 9.tremor of hands 10.characterchange 11.Marked obesity 12.marked emaciation13.hirsutism 14.alopecia 15.Hyperpigmentation 16.se*ual function change_Neurological system:1.None 2.Dizziness 3.headache
6、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.my
7、algia 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.None 2.Yes 3.Not clearVaccine detail _Trauma and/or operation history:Operations:1.None 2.Yes Operat
8、ion details:_Traumas:1.None 2.Yes Trauma details:_Blood transfusion history:1.None 2.Yes ( 1.Whole blood 2.Plasma 3.Ingredient transfusion) Blood type:_ Transfusion time:_ Transfusion reaction 1.None 2.Yes Clinic manifestation:_Allergic history: 1.None 2.Yes 3.Not clearallergen:_clinical manifestation:_Personal history:Custom living address:_Resident history in endemic disease area:_Smoking:1.No 2.YesAverage _pieces per day; about_yearsGiving-up 1.No 2.Yes (Time:_)Drinking: 1.No 2.YesAverage _grams per day; about _yearsGiving-u
