英文病历书写模板 medical history questionnaire
医学英语病历范文
医学英语病历范文Medical RecordPatient Information:Name: John SmithAge: 45Gender: MaleDate of admission: [Date]Date of birth: [Date]Weight: [Weight]Height: [Height]Chief complaint:Mr. Smith presents with a severe headache that has been ongoing for the past two days.History of present illness:The patient reports experiencing a sudden onset of throbbing headache, localized primarily on the left side of his head. The pain is aggravated by physical exertion and is accompanied by nausea and sensitivity to light and sound. The patient denies any recent head trauma or sinus congestion. Over-the-counter pain relievers have provided minimal relief.Medical history:Mr. Smith has a history of hypertension, for which he takes medication. He does not have any known allergies, and there is no family history of migraines or neurological disorders.Social history:The patient is a smoker, consuming approximately 10 cigarettes per day. He drinks alcohol in moderation, primarily on social occasions. He denies any illicit drug use. His occupation involves long hours of computer work.Physical examination:On examination, the patient appears to be in mild distress due to the headache. His vital signs are within normal limits. Neurological examination reveals no focal deficits, and his cranial nerves appear to be intact. There is no evidence of meningeal irritation. His neck is supple, and there is no nuchal rigidity. The remainder of the physical examination is unremarkable. Laboratory tests:Blood tests, including a complete blood count and comprehensive metabolic panel, were performed. All results were within normal limits.Imaging studies:A brain MRI was ordered to rule out any structural abnormalities. The scan revealed no evidence of intracranial hemorrhage, mass, or other abnormalities.Assessment and plan:Mr. Smith is presenting with a severe headache consistent with a migraine without aura. He will be prescribed a triptan medication for acute management of his headache. He will also be counseled on lifestyle modifications, including smoking cessation and stress reduction techniques. A follow-up appointment will be scheduled in two weeks to evaluate the effectiveness of the treatment plan.Additionally, the patient is advised to seek immediate medical attention if his symptoms worsen or if he develops any new neurological symptoms.Signature: [Physician's Name]Date: [Date]。
英语病历报告作文格式
英语病历报告作文格式English:A medical record report in English typically follows a specific format to ensure clear and organized documentation of a patient's medical history, diagnosis, treatment, and progress. The report usually starts with the patient's demographic information, including their name, age, gender, address, and contact information. This is followed by the reason for the patient's visit or hospitalization, including the chief complaint and any relevant medical history. The report then details the physical examination findings, laboratory and imaging test results, diagnosis, treatment plan, and prognosis. It is important to use clear and concise language, medical terminology, and abbreviations to accurately convey the patient's medical information. Additionally, proper grammar, spelling, and punctuation should be used to ensure professionalism and accuracy in the medical record report.中文翻译:英文病历报告通常遵循特定的格式，以确保清晰有序地记录患者的病史、诊断、治疗和进展情况。
英语病历作文格式模板
英语病历作文格式模板英文回答：Medical History Template。
Patient Information。
Name:Date of Birth:Address:Phone Number:Email:Insurance Information:Chief Complaint。
A brief summary of the patient's primary reason for the visit.Example: "The patient presents with a 3-day history of fever and chills."History of Present Illness。
A detailed description of the patient's symptoms, including:Onset: When did the symptoms first appear?Duration: How long have the symptoms been present?Severity: How severe are the symptoms?Location: Where are the symptoms located?Associated symptoms: Any other symptoms that are present, such as nausea, vomiting, or headache.Past Medical History。
A list of any previous medical conditions, surgeries, or hospitalizations.Example: "The patient has a history of hypertension and hyperlipidemia."Family History。
英文病历报告作文模板
英文病历报告作文模板Patient Information- Name: [Patient's Full Name]- Gender: [Male/Female]- Age: [Patient's age]- Date of Admission: [MM/DD/YYYY]Chief ComplaintThe patient presented with [specific symptoms/complaints] which started [duration].History of Present IllnessThe patient reported [detailed description ofsymptoms/complaints]. The symptoms worsened over the past [duration]. The patient experienced [associated symptoms] and tried [any self-medication or home remedies] but noticed no improvement. There was no history of trauma or injury.Past Medical HistoryThe patient has a history of [chronic/acute medical conditions, if any] which includes [specific conditions]. The patient has taken[previous medications/treatments] for these conditions.Social HistoryThe patient has a [specific occupation] and lives in [specific area]. The patient does [specific habits] such as smoking or drinking alcohol [frequency]. There is no significant family medical history.Physical Examination- Vital Signs:- Blood Pressure: [value] mmHg- Heart Rate: [value] bpm- Respiratory Rate: [value] bpm- Temperature: [value]C- General Appearance:The patient appears [general appearance of the patient].- Systemic Examination:- Cardiovascular: [specific findings]- Respiratory: [specific findings]- Gastrointestinal: [specific findings]- Neurological: [specific findings]- Musculoskeletal: [specific findings]Laboratory and Imaging Findings- Blood Test Results:- Complete Blood Count: [values]- Biochemical Profile: [values]- Others: [specific findings]- Imaging:- [Specific imaging tests performed]- Results: [specific findings]DiagnosisAfter evaluating the patient's medical history, physical examination, and laboratory/imaging findings, the following diagnosis was made:[Primary Diagnosis]Treatment and ManagementThe patient was started on [specific treatment plan] which includes [medications, therapies, or procedures]. The patient wasadvised to [specific instructions] and scheduled for [follow-up tests/appointments, if any].Follow-upThe patient will be followed up in [specific time frame] to assess the response to treatment and manage any complications that may arise. The patient was given contact information for any urgent concerns or changes in symptoms.Discussion and ConclusionThis case report highlights the presentation, evaluation, and management of a patient with [specific condition]. The patient's symptoms were appropriately addressed through a systematic approach involving history taking, physical examination, and laboratory/imaging investigations. The provided treatment plan aims to address the underlying cause and improve the patient's overall well-being. Continuous monitoring and follow-up will guide further management decisions.Note: This medical case report is fictional and serves as a template for educational purposes. Any resemblance to actualpatients is purely coincidental.。
英语病历报告作文格式
英语病历报告作文格式英文回答：Medical Report Format.The medical report format varies depending on the purpose and intended audience of the report. However, there are some general guidelines that can be followed whenwriting a medical report.The report should be organized into the following sections:Introduction: This section should provide a brief overview of the patient's condition, including the reasonfor the report.Medical History: This section should include adetailed account of the patient's medical history,including any previous illnesses, surgeries, or medications.Physical Examination: This section should describe the patient's physical examination findings, including vital signs, general appearance, and any abnormalities.Laboratory and Imaging Studies: This section should summarize the results of any laboratory tests or imaging studies that have been performed.Diagnosis: This section should provide a diagnosis of the patient's condition, based on the information gathered in the previous sections.Treatment Plan: This section should outline the treatment plan that has been recommended for the patient.Prognosis: This section should provide an estimate of the patient's prognosis, including the expected course of treatment and the likelihood of recovery.The report should be written in clear and concise language, using medical terminology where appropriate. Itshould also be organized in a logical way, with eachsection building on the previous one.中文回答：病历报告格式。
医学英语病历书写范文
医学英语病历书写范文Here is a 1,000 word essay on the topic of "Sample Medical English Patient Record":The importance of accurate and comprehensive patient record-keeping cannot be overstated in the medical field. Properly documenting a patient's history, symptoms, diagnosis, and treatment plan is crucial for providing high-quality, coordinated care. This is especially true when dealing with complex or chronic conditions that require ongoing monitoring and management.When writing a patient record, the primary goal should be to create a clear, concise, and easily understandable document that can be effectively utilized by the entire healthcare team. This means organizing the information in a logical, structured format and using standardized medical terminology and abbreviations appropriately.The first section of the patient record is typically the chief complaint, which succinctly describes the primary reason for the patient's visit. This should be a brief, one to two sentence summary stated in the patient's own words, such as "severe chest pain" or "persistent cough and difficulty breathing."Next, the history of present illness (HPI) provides more detailed information about the current health issue. This section should cover the timeline of symptom onset and progression, any aggravating or alleviating factors, associated signs and symptoms, and previous treatments tried. The HPI allows the clinician to develop a comprehensive understanding of the patient's condition.The past medical history section documents the patient's broader health background, including any chronic diseases, prior hospitalizations or surgeries, and relevant family health history. Capturing this contextual information is vital, as it can greatly inform the diagnostic process and guide appropriate management.The review of systems (ROS) involves systematically inquiring about and documenting pertinent positive and negative findings across all major body systems. This thorough assessment helps identify any additional medical issues that may be relevant, even if not directly related to the chief complaint.The physical examination portion of the record details the clinician's observations and measurements from the hands-on assessment. This can include vital signs, general appearance, specific findings from each body system examination, and any diagnostic test results. Clear, objective language should be used to describe the relevant physicalexam elements.Based on the information gathered in the previous sections, the assessment and plan section provides the clinician's medical decision-making. This includes the patient's working diagnosis or problem list, the rationale supporting this conclusion, and the proposed treatment strategy. The plan may involve medication prescriptions, referrals to specialists, recommended lifestyle modifications, and plans for ongoing monitoring and follow-up.Throughout the patient record, it is critical to use standardized medical terminology and abbreviations correctly. This ensures accurate communication and reduces the risk of ambiguity or misinterpretation. Additionally, all entries should be dated, timed, and signed by the responsible clinician.Proper documentation not only supports effective patient care, but also has important legal and financial implications. Patient records may be used as evidence in malpractice cases, to justify insurance claims, or to demonstrate compliance with regulatory requirements. Clinicians must be diligent in creating thorough, high-quality records that fully capture the patient encounter.Beyond these general principles, the specific formatting and required elements of a patient record can vary somewhat based on thehealthcare setting, clinical specialty, and organizational policies. For example, emergency department visit notes may have a different structure than those for outpatient primary care appointments.Regardless of the particular template used, the overarching goals remain the same - to document the patient's story in a clear, comprehensive, and legally-defensible manner. By mastering the art of effective medical record-keeping, clinicians can strengthen interprofessional communication, enhance continuity of care, and ultimately improve patient outcomes.。
英文病历书写范例
英文病历书写范例（内科）Medical Records for AdmissonMedical Number: 701721General informationName: Liu SideAge: EightySex: MaleRace: HanNationality: ChinaAddress: NO.35, Dandong Road, Jiefang Rvenue, Hankou, Hubei.Tel: 857307523Occupation: RetiredMarital status: MarriedDate of admission: Aug 6th, 2001Date of record: 11Am, Aug 6th, 2001Complainer of history:patient’s son and wifeReliability: ReliableChief complaint: Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for fo ur hours.Present illness:The patient felt upper bellyache about ten days ago. He didn’t pay attention to it and thought heha date something wrong. At 6 o’cloc k this morning he fainted and rejected lots of blood and gore. T hen hemafecia began. His family sent him to our hospital and received emergent treatment. So the patient was accepted because of “upper gastrointestine hemorrhage and exsanguine shock”. Since the disease coming on, the patient didn’t urinate. Past historyThe patient is healthy before.No history of infective diseases. No allergy history of food and drugs.Past history Operative history: Never undergoing any operation. Infectious history: No history of s evere infectious disease. Allergic history: He was not allergic to penicillin or sulfamide. Respirator y system: No history of respiratory disease. Circulatory system: No history of precordial pain. Ali mentary system: No history of regurgitation.Genitourinary system: No history of genitourinary disease.Hematopoietic system: No history of anemia and mucocutaneous bleeding. Endocrine system: No acromegaly. No excessive sweats. Kinetic system: No history of confinement of limbs. Neural sys tem: No history of headache or dizziness. Personal historyHe was born in Wuhan on Nov 19th, 1921 and almost always lived in Wuhan. His living condition s were good. No bad personal habits and customs.Menstrual history: He is a male patient. Obstetrical history: NoContraceptive history: Not clear.Family history: His parents have both deads. Physical examinationT 36.5℃, P 130/min, R 23/min, BP 100/60mmHg. He is well developed and moderately nourished.Active position. His consciousness was not clear. His face was cadaverous and the skin was not sta ined yellow. No cyanosis. No pigmentation. No skin eruption. Spider angioma was not seen. No pi tting edema. Superficial lymph nodes were not found enlarged. HeadCranium: Hair was black and white, well distributed. No deformities. No scars. No masses. No ten derness.Ear: Bilateral auricles were symmetric and of no masses. No discharges were found in external au ditory canals. No tenderness in mastoid area. Auditory acuity was normal.Nose: No abnormal discharges were found in vetibulum nasi. Septum nasi was in midline. No nare s flaring. No tenderness in nasal sinuses. Eye: Bilateral eyelids were not swelling. No ptosis. No e ntropion. Conjunctiva was not congestive. Sclera was anicteric. Eyeballs were not projected or dep ressed. Movement was normal. Bilateral pupils were round and equal in size. Direct and indirect p upillary reactions to light were existent.Mouth: Oral mucous membrane was not smooth, and there were ulcer can be seen. Tongue was in midline. Pharynx was congestive. Tonsils were not enlarged.Neck: Symmetric and of no deformities. No masses. Thyroid was not enlarged. Trachea was in mi dline. ChestChestwall: Veins could not be seen easily. No subcutaneous emphysema. Intercostal space was nei ther narrowed nor widened. No tenderness.Thorax: Symmetric bilaterally. No deformities. Breast: Symmetric bilaterally.Lungs: Respiratory movement was bilaterally symmetric with the frequency of 23/min. thoracic e xpansion and tactile fremitus were symmetric bilaterally. No pleural friction fremitus. Resonance was heard during percussion. No abnormal breath sound was heard. No wheezes. No rales. Heart: No bulge and no abnormal impulse or thrills in precordial area. The point of maximum imp ulse was in 5th left intercostal space inside of the mid clavicular line and not diffuse. No pericardi al friction sound. Border of the heart was normal. Heart sounds were strong and no splitting. Rate 150/min. Cardiac rhythm was not regular. No pathological murmurs.Abdomen: Flat and soft. No bulge or depression. No abdominal wall varicosis. Gastralintestinal ty pe or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. T here was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill negative. Shifting dullness negative. Borhorygmus not heard. No vascular mur murs. Extremities: No articular swelling. Free movements of all limbs.Neural system: Physiological reflexes were existent without any pathological ones. Genitourinary system: Not examed. Rectum: not exanedInvestigationBlood-Rt: Hb 69g/L RBC 2.70T/L WBC 1. 1G/L PLT 120G/L History summary1. Patient was male, 80 years old2. Upper bellyache ten days, haematemesis, hemafecia and unconsciousness for four hours.3. No special past history.4. Physical examination: T 37.5℃, P 130/min, R 23/min, BP 100/60mmHg Superficial lymph node s were not found enlarged. No abdominal wall varicosis. Gastralintestinal type or peristalses were not seen. Tenderness was obvious around the navel and in upper abdoman. There was not rebound tenderness on abdomen or renal region. Liver and spleen was untouched. No masses. Fluidthrill ne gative. Shifting dullness negative. Borhorygmus not heard. No vascular murmurs. No other positive signs. 5. investigation information:Blood-Rt: Hb 69g/L RBC 2.80T/L WBC 1.1G/L PLT 120G/LImpression: upper gastrointestine hemorrhage Exsanguine shock出院小结（DISCHARGE SUMMARY）， ===============Department of GastroenterologyChanghai Hospital，No.174 Changhai Road Shanghai, China Phone: 86-21-25074725-803 DISCHARGE SUMMARYDA TE OF ADMISSION: October 7th, 2005 DA TE OF DISCHARGE: October 12th, 2005 ATTE NDING PHYSICIAN: Yu Bai, MD PA TIENT AGE: 18ADMITTING DIAGNOSIS:V omiting for unknown reason: acute gastroenteritis?BRIEF HISTORYA 18-year-old female with a complaint of nausea and vomiting for nearly one month who was see n at Department of Gastroenterology in Changhai Hospital, found to have acute gastroenteritis and non-atrophic gastritis. The patient was subsequently recovered and discharged soon after medicati on.REVIEW OF SYSTEMShe has had no headache, fever, chills, diarrhea, chest pain, palpitations, dyspnea, cough, hemopty sis, dysuria, hematuria or ankle edema.PAST MEDICAL HISTORYShe has had no previous surgery, accidents or childhood illness.SOCIAL HISTORY: She has no history of excessive alcohol or tobacco use.FAMIL Y HISTORYShe has no family history of cardiovascular, respiratary and gastrointestinal diseases. PHYSICAL EXAMINA TIONTemperature is 37, pulse 80, respirations 16, blood pressure 112/70. General: Plump girl in no app arent distress. HEENT: She has no scalp lesions. Her pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae are anicteric. Oropharynx is clear. There is no thyromegaly. There is no cervical or supraclvicular lymphadenopathy. Cardiovascular: Regular rate andrhythm, normal S1, S2. Chest: Clear to auscultation bilateral. Abdomen: Bowel sounds present, no hepatosplenomagaly. Extremities: There is no cyanosis, clubbing or edema. Neurologic: Cranial n erves II-XII are intact. Motor examination is 5/5 in the bilateral upper and lower extremities. Sens ory, cerebellar and gait are normal.LABORATORY DATAWhite blood cells count 5.9, hemoglobin 111g/L, hematocrit 35.4. Sodium 142, potassium 4.3, chl oride 106, CO2 25, BUN 2.6mmol/L, creatinine 57μmol/L, glucose 4.1mmol/L, Albumin 36g/L. Endoscopic ExamChronic non-atrophic gastritisHOSPITAL COURSEThe patient was admitted and placed on fluid rehydration and mineral supplement. The patient im proved, showing gradual resolution of nausea and vomiting. The patient was discharged in stable c ondition.DISCHARGE DIAGNOSIS Acute gastroenteritisChronic non-atrophic gastritisPROGNOSISGood. No medications needed after discharge. But if this patient can not get used to Chinese food, she had better return to UK as soon as possible to prevent the relapse of acute gastroenteritis. The patient is to follow up with Dr. Bai in one week. ___________________________ Yu Bai, MD D: 12/10/2005。
英语病历模板范文
英语病历模板范文Patient Identification:Date of Birth: [DOB]Sex: [Male/Female]Patient ID: [Unique Identifier]Chief Complaint:[Patient's primary concern or reason for the visit, e.g., "Severe headache for the past 3 days"]History of Present Illness:[Detailed account of the onset, duration, severity, and any associated symptoms of the current illness. Include any treatments already attempted.]Past Medical History:[List any previous medical conditions, surgeries, or hospitalizations.]Medications:[List all current medications, including dosages andfrequency.]Allergies:[Note any known allergies to medications, foods, or environmental factors.]Family Medical History:[Provide information on any significant medicalconditions in the patient's family.]Social History:[Include relevant lifestyle factors such as smoking status, alcohol consumption, exercise habits, and occupation.]Review of Systems:[Briefly summarize the patient's current state inrelation to various body systems, e.g., "No chest pain, no shortness of breath."]Physical Examination:[Record findings from the physical examination, including vital signs, general appearance, and specific observations related to the chief complaint.]Assessment:[Summarize the likely diagnosis or condition based on the information gathered.]Plan:[Outline the proposed treatment plan, including medications, referrals, follow-up appointments, and any necessary tests or procedures.]。
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Medical History Questionnaire
NAME: _________________________________________
TODAY’S DATE: __________________ First Middle Initial Last
DATE OF BIRTH: __________________
This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching diagnosis and determining the source of your problem. Please take your time and answer each question as completely and honestly as possible. Please sign every page.
N Antibiotics Y N Latex
Y N Sedatives N Aspirin
Y N Local anesthetics Y N Sleeping pills N Barbiturates Y N Metals Y N Sulfa drugs
N Codeine Y N Penicillin Y N N
Iodine
Y N
Plastic
Y N
Other ______________________ ________________________ _________________________
LIST ANY MEDICATIONS CURRENTLY BEING TAKEN:
Medication
Dosage/Frequency
Reason
_________________________ _____________________ _______________________________________________ _________________________ _____________________ _______________________________________________ _________________________ _____________________ _______________________________________________ _________________________ _____________________
_______________________________________________ MEDICAL HISTORY: (Please indicate dates on items marked current or past)
Medical Condition
Medical Condition
Acid reflux
Insomnia
Adenoids Removed
Intestinal disorder Anemia
Jaw joint surgery Arteriosclerosis
Kidney problems Arthritis
liver disease Asthma
Low energy
Autoimmune disorder Meniere's disease Bleeding easily
Menstrual cramps Blood pressure - High
Multiple sclerosis Blood pressure - Low Muscle aches
Botox
Muscle shaking (tremors) Bruising easily
Muscle spasms or cramps Cancer
Muscular dystrophy Chemotherapy
Nasal allergies
Chronic cough
Needing extra pillow to help Chronic fatigue
breathing at night
Chronic pain
Nervous system irritability Cold hands and feet Nervousness COPD
Neuralgia
Depression
Numbness of fingers Diabetes
Osteoarthritis Difficulty concentrating
Osteoporosis
Patient Signature ______________________________ Date _________________________ Page 1
Medical condition Never Current Past Medical condition Never Current Past
Difficulty sleeping Ovarian cysts Dizziness Parkinson's disease Emphysema Poor circulation
Epilepsy Prior orthodontic treatment Excessive thirst Psychiatric care Fibromyalgia Radiation treatment Fluid retention Rheumatic fever Frequent cough Rheumatoid arthritis Frequent illnesses
Scarlet fever Frequent stressful situations Scoliosis
General anesthesia Shortness of breath Glaucoma Sinus problems Gout Skin disorder Hay Fever Sleep apnea Hearing impaired Slow healing sores Heart attack
Speech difficulties Heart disorder Stroke
Heart murmur Swelling in ankles or feet Heart pacemaker Swollen, stiff or painful joints Heart valve replacement Tendency for ear infections Hemophilia Tendency for frequent colds Hepatitis Tendency for sore throats Hypertension Thyroid disorder Hypoglycemia
Tired muscles Immune system disorder Tonsils removed Injury to face Tuberculosis Injury to mouth Tumors Injury to neck
Urinary disorders Injury to teeth
Wisdom teeth extraction
Medical condition
Medical condition Other ____________________
ADDITIONAL MEDICAL HISTORY ITEMS:
Recreational Drugs HIV/AIDS
N Appendectomy Y N Heart
Y
N Thyroid
N Back Y N Hernia repair Y N Tonsillectomy
N Ear
Y N Lung Y N Uvulectomy N
Gallbladder
Y N
Nasal
Y N
Periodontal
Patient Signature _________________________________
Date____________________
Page 2
FAMILY HISTORY Has any member of your family had (parent, sibling or grandparent):
Y
N
Cancer Y
N
Sleep disorder Y
N
Father snores
Y N Heart disease Y N Obesity Y N
Mother snores
Y
N
Diabetes
Y N
Thyroid trouble
Y
N
Father has sleep apnea Y N Stroke Y N High blood pressure Y N Mother has sleep apnea SOCIAL HISTORY:
Tobacco Use:smoked
Alcohol Use:
Caffeine Intake:None Coffee/Tea/Soda #cups per day: _______
Additional:
Page 3。