2. Chief complaint: the most important and obvious symptoms or signs of the patient.
3. Current medical history: onset time and onset time, main symptoms, development and evolution of illness, accompanying symptoms, diagnosis, treatment and nursing process.
4. Functional health forms of human body: such as nutrition and metabolism, excretion, activity and exercise, sleep and rest.
Extended data:
Matters needing attention in consultation:
1, with a high degree of seriousness and responsibility. Treat patients with a serious and kind attitude, ask questions, and patiently listen to patients' descriptions of their illness.
2. Ask questions in a popular way, and don't use medical terms that are difficult for patients to understand. For example, you ask a patient with liver depression and qi stagnation, "Do you have hypochondriac pain?" Ask a cold patient, "Do you hate cold?"
The "hypochondriac pain" and "aversion to cold" mentioned here are medical terms, which are not easy for patients without professional knowledge of traditional Chinese medicine to understand. Therefore, doctors should pay attention to avoid using technical terms when asking questions. When you need to ask questions, you can ask them in easy-to-understand language such as "Does it hurt" and "Are you afraid of the cold".
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