Name: ______________ Sex: __________ Age: ___________ Nation: ___________ Birth Place: ________________________________ Marital Status:____________ Work-organization & Occupation: _______________________________________ Living Address & Tel: _________________________________________________ Date of admission: _______Date of history taken:_______ Informant:__________ Chief Complaint: ___________________________________________________ History of Present Illness:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Past History:
General Health Status: 1.good 2.moderate 3.poor
Disease history: (if any, please write down the date of onset, brief diagnostic
and therapeutic course, and the results.)
I
Division: __________ Ward: __________ Bed: _________ Case No. ___________
Respiratory system:
1. None 2.Repeated pharyngeal pain 3.chronic cough 4.expectoration:
5. Hemoptysis 6.asthma 7.dyspnea 8.chest pain
_______________________________________________________________ Circulatory system:
1.None 2.Palpitation 3.exertional dyspnea 4..cyanosis 5.hemoptysis
6.Edema of lower extremities 7.chest pain 8.syncope 9.hypertension
_______________________________________________________________ Digestive system:
1.None 2.Anorexia 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 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.epistaxis
6.subcutaneous hemorrhage
_______________________________________________________________ Metabolic and endocrine system:
1.None 2.Bulimia 3.anorexia 4.hot intolerance 5.cold intolerance
6.hyperhidrosis 7.Polydipsia 8.amenorrhea
9.tremor of hands 10.character change 11.Marked obesity 12.marked emaciation 13.hirsutism 14.alopecia 15.Hyperpigmentation 16.sexual function change
_______________________________________________________________ Neurological system:
1.None 2.Dizziness 3.headache 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.myalgia 8.muscular atrophy
_______________________________________________________________ Infectious Disease:
II
Division: __________ Ward: __________ Bed: _________ Case No. ___________
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 clear
Vaccine detail __________________________________________
Trauma and/or operation history: Operations: 1.None 2.Yes
Operation 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 clear
allergen:________________________________________________ clinical manifestation:_____________________________________
Personal history:
Custom living address:____________________________________________ Resident history in endemic disease area:_____________________________ Smoking: 1.No 2.Yes
Average ___pieces per day; 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 age: __________years old Pregnancy ___________times Labor _______________times
III
Division: __________ Ward: __________ Bed: _________ Case No. ___________
(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: 1.Well 2.Not fine
Details: _______________________________________________
Menstrual history:
Menarchal age: _______ 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 present 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.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.active 2.positive 3.compulsive 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
IV
Division: __________ Ward: __________ Bed: _________ Case No. ___________
Skin eruption:1.No 2.Yes( 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: __________________________________________________________
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:_______________________
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 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:____________________ Gum :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:
V
Division: __________ Ward: __________ Bed: _________ Case No. ___________
Chest wall: 1.normal 2.barrel chest 3.prominence or retraction:
( left________right_________Precordial prominence__________)
Percussion pain over sternum 1.No 2.Yes
Breast: 1.Normal 2.abnormal _______________________________________ Lung: Inspection: respiratory movement 1.normal 2.abnormal_____________ Palpation: vocal tactile fremitus:1.normal 2.abnormal _______________
pleural rubbing sensation:1.no 2.yes______________________
Subcutaneous crepitus sensation:1.no 2.yes________________ Percussion:1. resonance 2. Hyperresonance &location_____________
3 Flatness&location_________________________________
4. dullness & location:_______________________________ 5.tympany &location:_______________________________ lower border of lung: (detailed percussion in respiratory disease)
midclavicular line : R:_____intercostae L:_____intercostae midaxillary line: R:______intercostae L:_____intercostae scapular line: R:______intercostae L:_____intercostae movement of lower borders:R:_______cmL:__________cm
Auscultation: Breathing sound : 1.normal 2.abnormal _______________ Rales:1.no 2.yes__________________________________ Heart: Inspection:Apical pulsation: 1.normal 2.unseen 3.increase 4.diffuse
Subxiphoid pulsation: 1.no 2.yes
Location of apex beat: 1.normal 2.shift (______ intercosta,
distance away from left MCL______cm)
Palpation:
Apical pulsation:1. normal 2.lifting apex impulse 3.negative pulsation
Thrill:1.no 2.yes(location:___________ phase:_________________) Percussion: relative dullness border: 1.normal 2.abnormal Right(cm) Anterior midline Left(cm) II III IV V (Distance between Anterior Medline and left MCL _______cm) Auscultation: Heart rate:___bpm Rhythm:1.regular 2.irregular_______ Heart sound: 1.normal 2.abnormal________________________ Extra sound: 1.no 2.S3 3.S4 4. opening snap
P2_________ A2_________Pericardial friction sound:1.no 2.yes
Murmur: 1.no 2.yes (location____________phase_____________
quality______intensity________ transmission___________
effects of position_________________________________
effects of respiration______________________________
Peripheral vascular signs:
VI
Division: __________ Ward: __________ Bed: _________ Case No. ___________
1.None 2.paradoxical pulse 3.pulsus alternans 4. Water hammer pulse
5.capillary pulsation 6.pulse deficit 7.Pistol shot sound 8.Duroziez sign
Abdomen:
Inspection: Shape: 1.normal 2.protuberance 3.scaphoid 4.frog-belly Gastric pattern 1.no 2.yes Intestinal pattern 1.no 2.yes Abdominal vein varicosis 1.no 2.yes(direction:______________ ) Operation scar1.no 2.yes ________________________________ Palpation: 1.soft 2. tensive (location:____________________________)
Tenderness: 1.no 2.yes(location:_______________________) Rebound tenderness:1.no 2.yes(location:________________) Fluctuation: 1.present 2.abscent Succussion splash: 1.negative 2.positive
Liver:_______________________________________________ Gallbladder: __________________Murphy sign:____________ Spleen:______________________________________________ Kidneys:____________________________________________ Abdominal mass:______________________________________ Others:______________________________________________
Percussion: Liver dullness border: 1.normal 2.decreased 3.absent
Upper hepatic border:Right Midclavicular Line ________Intercosta Shift dullness:1.negative 2.positive Ascites:_____________degree Pain on percussion in costovertebral area: 1.negative 2.positve ____
Auscultation: Bowel sounds : 1.normal 2.hyperperistalsis 3.hypoperistalsis
4.absence Gurgling sound:1.no 2.yes
Vascular bruit 1.no 2.yes (location_____________________)
Genital organ: 1.unexamined 2.normal 3.abnormal Anus and rectum: 1.unexamined 2.normal 3.abnormal Spine and extremities:
Spine: 1.normal 2.deformity (1.kyphosis 2.lordosis 3.scoliosis)
3.Tenderness(location______________________________) Extremities: 1.normal 2.arthremia & arthrocele (location_________________) 3.Ankylosis (location__________) 4.Aropachy: 1.no 2.yes
5.Muscular atrophy (location_______________________)
Neurological system:1.normal 2.abnormal_______________________________
_____________________________________________________________________
Important examination results before hospitalized
VII
Division: __________ Ward: __________ Bed: _________ Case No. ___________
___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Summary of the history:______________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Initial diagnosis:_____________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
Recorder: Corrector:
VIII
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