(1) General project
Name, gender, age, place of origin, birthplace, nationality, marriage, mailing address, telephone number, work unit, occupation, date of admission, date of recording, medical history presenter and reliability, etc.
(2) Chief complaint
Feel the main pain or the most obvious symptoms or (and) signs for patients, which is the main reason and duration of this visit. (No obvious incentive) No more than 20 words.
(3) Current medical history
The main part of the medical history describes the whole process of the patient after illness, that is, the occurrence, development, evolution and diagnosis and treatment process. (Six points of block: position, size, texture, fluidity, adhesion and breakage)
1. onset and onset time
2. Characteristics of main symptoms
3. Etiology and inducement
4. Development and evolution of diseases
5. Concurrent certificate
6. Diagnosis and treatment process
7. General situation in the process of disease
(4) Past history
The patient's past health status and past diseases (including various infectious diseases, hypertension, diabetes, coronary heart disease, trauma), trauma surgery, vaccination, allergies, etc. , especially diseases closely related to current diseases. (Is there any long-term medication? )
(5) Systematic review
Respiratory system, blood system, circulatory system, endocrine and metabolic system, digestive system, nervous system, urinary system, musculoskeletal system.
(6) Personal history
1. Social experience includes place of birth, place of residence and time of residence (especially epidemic areas and epidemic areas), education level, economic life and hobbies. Different infectious diseases have different incubation periods. According to the disease you are considering, you should ask whether you have been to an epidemic spot in the past.
2. Occupation and working conditions include work type, working environment, exposure to industrial poisons and time.
3. Habits and hobbies The regularity and quality of daily life, as well as hygiene habits and diet. Time and intake of tobacco and alcohol hobbies, as well as other heterosexual and narcotic drugs and drugs.
4. Whether there is a history of vagrancy, whether you have suffered from gonococcal urethritis, condyloma acuminatum, chancre, etc.
(7) Marriage history
Unmarried or married, marriage age, spouse health, sex life, husband-wife relationship, etc.
(eight) menstrual history and birth history.
Menarche age, menstrual period (days), menstrual cycle (days), last menstrual time LMP or menopausal age.
Number of pregnancies and deliveries, number of induced or spontaneous abortions, stillbirth, surgical delivery, perinatal infection, family planning, contraceptive measures (safety period, contraceptive pills, contraceptive rings, uterine caps, condoms, etc.). ), etc.
(9) Family history