非手术科室住院志英文病历模板(修改版).doc

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1、Division:__________Ward:__________Bed:_________CaseNo.___________HUAZHONGUNIVERSITYOFSCIENCEANDTECHNOLOGYTONGJIMEDICALCOLLEGEACCESSORYTONGJIHOSPITALHospitalizationRecordsforNone-operationDivisionDivision:__________Ward:__________Bed:_________CaseNo.___________Name:______________Sex:__________Age:__

2、_________Nation:___________BirthPlace:________________________________MaritalStatus:____________Work-organization&Occupation:_______________________________________LivingAddress&Tel:_________________________________________________Dateofadmission:_______Dateofhistorytaken:_______Informant:_________

3、_ChiefComplaint:___________________________________________________HistoryofPresentIllness:________________________________________________________________________________________________________________________________________________________________________________________________________________

4、___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5、___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6、____________________VIIIDivision:__________Ward:__________Bed:_________CaseNo.___________PastHistory:GeneralHealthStatus:1.good2.moderate3.poorDiseasehistory:(ifany,pleasewritedownthedateofonset,briefdiagnosticandtherapeuticcourse,andtheresults.)Respiratorysystem:1.None2.Repeatedpharyngealpain3.chr

7、oniccough4.expectoration:5.Hemoptysis6.asthma7.dyspnea8.chestpain_______________________________________________________________Circulatorysystem:1.None2.Palpitation3.exertionaldyspnea4..cyanosis5.hemoptysi