Including: name, gender, age, native place, birthplace, nationality, marriage, address, work unit, occupation, date of admission, date of recording, medical history presenter and reliability, etc. If the person presenting the medical history is not himself, his relationship with the patient should be indicated. When recording age, you should fill in the actual age, and you can't use "son" or "success" instead, because age itself has diagnostic reference significance.
(2) Chief complaint
Patients feel the most important pain or the most obvious symptoms and signs, which is the most important reason for seeing a doctor. The chief complaint should be concise, summarized in one or two sentences, and indicate the time from onset to treatment.
(3) Current medical history
The main part of medical history, including the whole process of disease occurrence, development and evolution, is the key content in consultation. Mainly includes the following aspects:
1. onset (priority) and onset time.
2. The characteristics of main symptoms, including location, radiation area, nature, attack frequency, duration, intensity, aggravating or mitigating factors.
3. Causes and incentives.
4. The development and evolution of the disease (recorded in chronological order, including the development of main symptoms and other related symptoms).
5. Accompanying symptoms.
6. Diagnosis and treatment (drugs, dosage, curative effect, etc. ).
7. General conditions since the onset (mental state, appetite, weight change, sleep and defecation, etc. ).
8. Induce, summarize and re-verify.
9. Ask questions about the past history in interlanguage.
(4) Past history
Also known as "past tense". Including:
1. The patient's past health status.
2. Past diseases (including various infectious diseases), especially the disease history closely related to the present medical history. For example, patients with coronary atherosclerotic heart disease should ask whether they had hypertension or diabetes in the past. Care should be taken not to confuse the description with the current medical history.