Name:No. □□□□□ -□□□□□□□□□
Physical examination date
date month year
A responsible doctor
Internal capacity
inspection item
disease
shape
1 asymptomatic 2 headache 3 dizziness 4 palpitation 5 chest tightness 6 chest pain 7 chronic cough 8 expectoration 9 dyspnea 10 drink more.
1 1 polyuria 12 weight loss 13 fatigue 14 joint pain 15 blurred vision 16 numbness of hands and feet 17 urgency17 urgency.
19 constipation 20 diarrhea 2 1 nausea and vomiting 22 dizziness 23 tinnitus 24 breast pain 25 others
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one
kind
shape
situation
temperature
℃
Pulse rate
Times/minute
respiratory rate
Times/minute
blood pressure
left
/mmhg
frontage
/mmhg
height
centimetre
weight
kilogram
waistline
centimetre
Body mass index (BMI)
Kg/m2
Self-assessment of health status of the elderly *
1 satisfied 2 basically satisfied 3 unclear 4 dissatisfied 5 dissatisfied
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Self-assessment of self-care ability of the elderly *
1 Self-care (0 ~ 3 points) 2 Mild dependence (4 ~ 8 points)
3 moderate dependence (9 ~ 18) 4 inability to take care of themselves (≥ 19)
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the aged
Cognitive function *
1 coarse screen negative
2. Rough screening positive, simple mental state examination, total score
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the aged
Emotional state *
1 coarse screen negative
2. Rough screening is positive, and the depression score of the elderly is checked, with a total score.
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grow
alive
square
style
physical exercise
Exercise frequency
1 2 every day, more than once a week, 3 occasionally, 4 no exercise.
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Time for each practice
minute
Stick to exercise time
year
Exercise mode
eating habits
1 vegetarian balance 2 vegetarian diet 3 vegetarian diet 4 halophilic 5 oleophilic 6 sugar-loving
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Smoking situation
Smoking status
1 Never smoke 2 Quit smoking 3 Smoking
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Daily smoking volume
Average branch
The age at which smoking started.
year
Smoking cessation age
year
Drinking situation
Drinking frequency
1 never 2 occasionally 3 often 4 every day
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Daily alcohol consumption
Average two
Do you want to stop drinking?
1 Don't stop drinking 2 Stop drinking, age of abstinence: years old.
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Starting drinking age
year
Have you ever been drunk in the past year?
1 Yes 2 No
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Type of drinking
1 white wine 2 beer 3 red wine 4 yellow wine 5 others
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Exposure history of occupational hazard factors
1 no2 yes (years of working experience)
Poison type, dustproof measures, 1, No.2, yes.
There are no protective measures for radioactive substances 1.
Physical protection measures 1 not available.
There are no protective measures for chemicals 1.
Other protective measures 1 are not available.
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dirty
appliance
success
can
oral cavity
Lips 1 ruddy 2 pale 3 cyanosis 4 chapped 5 herpes
Dentition 1 Normal 2 Dentition 3 Dental Caries 4 Denture (Denture)
Pharyngeal 1 non-hyperemia 2 hyperemia 3 lymphofollicular hyperplasia
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Visual ability
Left eye and right eye (corrected vision: left eye and right eye)
Listening ability
1 hear clearly 2 can't hear clearly or can't hear clearly.
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motor function
1 can be completed successfully, and 2 cannot complete any action independently.
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cheque
body
Fundus *
1 normal 2 abnormal
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Skin skin
1 normal 2 flush 3 pallor 4 cyanosis 5 yellow dye 6 pigmentation 7 others
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Mo Gong
1 Normal 2 Yellow 3 Congestion 4 Other
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lymph node
1 untouched 2 supraclavicular 3 axillary 4 others
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lung
Bucket box: 1 No 2 Yes
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Breathing sound: 1 normal 2 abnormal
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Luo Yin: 1 None 2 Dry Luo Yin 3 Wet Luo Yin 4 Other
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heart
Heart rate times/min Heart rate: 1, even 2, even 3, absolutely even.
Noise: 1 No 2 Yes
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abdomen
Tender: 1, No.2, yes
Packing: 1 none 2 available
Hepatomegaly: 1, No.2, yes.
Spleen enlargement: 1 no 2.
Voiced mobile phone: 1 None 2 Yes
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edema of lower extremity
1 No 2 Unilateral 3 Bilateral Asymmetry 4 Bilateral Symmetry
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Pulse of dorsal foot artery
1 untouched 2 touches bilateral symmetry 3 touches the left side weakly or disappears 4 touches the right side weakly or disappears.
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Anal digital examination *
1 less than abnormal 2 tenderness 3 lump 4 abnormal prostate 5 others
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Breast *
1 No abnormality found; 2 mastectomy 3 abnormal lactation 4 breast lump 5 others.
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Gynecology *
hole
1 No abnormality found.
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vagina
1 No abnormality found.
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neck
1 No abnormality found.
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corpus uteri
1 No abnormality found.
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attachment
1 No abnormality found.
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Other *
supplement
help
check
cheque
Blood routine *
Hemoglobin _ _ _ _ _ _ _ _ _ g/liter of white blood cells _ _× 109/ liter of platelets _ _×109/liter.
Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Urine routine *
Urine protein _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Fasting blood glucose *
_ _ _ _ _ _ _ _ _ _ _ millimole/liter or _ _ _ _ _ _ _ _ _ mg/dl
ECG *
1 normal 2 abnormal
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Urine microalbumin *
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ mg/dl
Fecal occult blood *
1 negative 2 positive
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Glycosylated hemoglobin *
%
hepatitis B
Surface antigen *
1 negative 2 positive
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Liver function *
Serum alanine aminotransferase U/L
Albumin g/L Total bilirubin micromole/L
Binding bilirubin μmol/L
Renal function *
Serum creatinine μmol/L blood urea nitrogen mmol/L
Blood potassium concentration mmol/L blood sodium concentration mmol/L
Blood lipid *
Total cholesterol millimole/liter triglyceride millimole/liter
Serum low density lipoprotein cholesterol millimole/liter
Serum high density lipoprotein cholesterol millimole/liter
Chest x-ray film *
1 normal 2 abnormal
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B tide *
1 normal 2 abnormal
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Cervical smear *
1 normal 2 abnormal
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Other *
TCM Constitution Identification *
Pinghe quality
1 is 2, basically.
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deficiency of vital energy
1 is 2, and the trend is
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deficiency of yang
1 is 2, and the trend is
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deficiency of yin
1 is 2, and the trend is
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Phlegm dampness
1 is 2, and the trend is
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Damp heat constitution
1 is 2, and the trend is
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Blood stasis
1 is 2, and the trend is
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stagnation of the circulation of vital energy
1 is 2, and the trend is
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Special quality
1 is 2, and the trend is
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Main health problems
cerebrovascular disease
1 Not found 2 ischemic stroke 3 cerebral hemorrhage 4 subarachnoid hemorrhage 5 transient ischemic attack.
6 others
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Kidney disease
② Diabetic nephropathy ③ Renal failure ④ Acute nephritis ⑤ Chronic nephritis is found in 1.
6 others
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heart disease
1 No myocardial infarction, angina pectoris, coronary revascularization and congestive heart failure were found.
6 precordial pain 7 others
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angiopathy
1 2 dissecting aneurysms, 3 arterial occlusive diseases and 4 others were not found.
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eye trouble
1 No retinal hemorrhage or exudation, papilla edema and cataract were found.
5 others
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Nervous system diseases
1 No.2 was not found.
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Other system diseases
1 No.2 was not found.
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Hospitalization situation
Hospitalization history
Admission/discharge date
Primitive cause
Name of medical institution
Medical record number
/
/
Jiating
Sick bed history
Date of subgrade construction/demolition
Primitive cause
Name of medical institution
Medical record number
/
/
Main drugs
situation
Drug name
use
dosage
Time of taking medicine
Medication compliance
1 Rule 2 Intermittent 3 No drug treatment
1
2
three
four
five
six
Nonimmunity
Planning vaccination history
name
Vaccination date
Inoculation institution
1
2
three
health
evaluate
1 Normal physical examination □
There is something abnormal.
Exception 1
Exception 2
Anomaly 3
Exception 4
healthy
healthy
point to
guide
1 into the health management of patients with chronic diseases
2 suggested review
3 recommended recommendation
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Risk factor control: □/□/□/□
1 Quit smoking 2 Healthy drinking 3 Dieting 4 Exercise
5 lose weight (goal)
6 Vaccination is recommended
7 others