台中榮民總醫院xxxxxxx 科入院病歷摘要

台 中 榮 民 總 醫 院 xxxxxxx 科 入院病歷摘要 000000000A. ID. Name XXX. Birthday 00/00/00 (1911) Age. 00 year(s) old. General Data  婚姻 :  種族 :  人種 :  居住地區 :  職業 :  職稱 :  病史獲取來源:  訪 談 日 期 :YYYY/MM/DD  全民健保以外之醫療保險：. Chief Complaint . Present Illness . Past History  DM :  HTN :  Asthma :  Thyroid disease :  Hepatitis :  Operation :  Blood transfusion :  Gout :  Pulmonary/extrapulmonar y tuberculosis :. Personal History 1. Cigarette smoking :. Bed Number W00-000 Gender. Section Admission Date. 00/00/00 (2007).

2. Alcohol consumption : 3. Betel-nut chewing : 4. Tattoo: 5. Seuxal Histor y : 6. Drug abuse :. Travel History . Drug History 1. Chinese herb : 2. Food supplement : 3. Vitamins : 4. Medication at other hospital or clinic :. Allergy History 1. Drug : 2. Food : 3. Blood transfusion : 4. Environmental substance :. Family History  Family pedigree:  Thyroid disease :. Contact History  Animal:  Sick person:. Review Of System  General condition :  Skin :  Head :  Eye :  Ear :.

 Nose :  Mouth and throat :  Neck :  Breast :  Cardiovascular :  Respiratory :  Gastrointestinal :  Hematological :  Urinary :  Genito-reproduction :  Musculo-skeletal:  Neurological :  Ps ychiatric :  Endocrine:. Physical Examination  General appearance :  Vital signs :  Skin :  HEENT : o Head : o Eyes : o Ears : o Nose : o Throat :  Neck :  Chest : o Inspection : o Palpation : o Percussion : o Auscultation :  Heart : o Inspection : o Palpation :.

o Percussion : o Auscultation :  Abdomen : o Inspection : o Auscultation : o Percussion : o Palpation :  Back and spine : o Inspection: o Percussion: o Palpation:  Extremities :  Genito-anus :  Neurological examination :. Rheumatological Examination. Laboratory Data. Image. Current Medications. Impression (Assessment) . Plan to do. 審閱. /. 填寫.