Division: __________ Ward: __________ Bed: _________ Case No. ___________ 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.)
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
