澳门百家樂网站 > 澳门百家樂手机版官网资料 > 澳门百家樂娱乐场老人健康档案表
澳门百家樂娱乐场老人健康档案表

 


区域
          室号        床号        入住日期               住院号         

姓名                                   护理等级                                

性别                                   职业                                    

出生年月                               工作单位                              

民族           籍贯                    供病史者                              

家庭地址                              

主诉:

                                                                               

                                                                                
 

现病史:

                                                                                

                                                                               

 
既往史:(曾患疾病、既往体质)

                                                                                

                                                                                

体格检查:

体温                  脉搏              /分钟        呼吸          /分钟

血压                                

一般情况(1、以写慢性体征为主、2、皮肤、淋巴、心肺、腹、四肢活动情况、神经反射情况):

                                                                                  

                                                                                   

实验室检查:

                                                                                    

                                                                                    

初步诊断:

 

                                                                                    

 

                                                                                    

诊疗计划:

                                                                                    

                                                                                    

医师签名:                                                              


------------------------------------------------------------------------------------------------

老人病历档案

姓名:      性别:       年龄:    区域:     房号:     床号:     
入院时间:        

  诉:                                                                       

                                                                               

现病史:                                                                      

                                                                                                  

既往史:                                                                       

                                                                               

婚育史:                                                                                         

家族史:                                                                       

                                                                                 

体格检查情况:

体温:                     脉搏:                       呼吸:                             

血压:                  身高:               体重:              体表面积:       

体检描述:

皮肤:                                                                         

淋巴结:                                                                      

头颅:                                                                       

眼部:                                                                        

耳部:                                                                       

鼻部:                                                                        

口腔:                                                                        

颈部:                                                                          

胸部:                                                                         

血管:                                                                           

桡动脉:                                                                        

周围血管征:                                                                     

腹部:                                                                         

肛门及外生殖器:                                                               

脊柱及四肢:                                                                  

脊柱:                                                                        

四肢:                                                                         

神经系统:                                                                    

病历摘要:                                                                    

                                                                              

                                                   医生签名:

首次外出求医情况记录:                                                            

                                                                              

                                                                              

                                                    医生签名:

 

二次外出求医情况记录:                                                            

                                                                              

                                                   

                                                    医生签名:

 

 

三次外出求医情况记录:                                                        

                                                                              

                                                   

                                                   医生签名:

 

                                               

四次外出求医情况记录:                                                        

                                                                             

                                                                              

                                                    医生签名:

 

五次外出求医情况记录:                                                            

                                                                              

                                                   

                                                    医生签名:

 

 

六次外出求医情况记录:                                                          

                                                                             

                                                   

                                                   医生签名: