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Medical Chart
Patient's identification Date of Entrance: ,Time: ,ID: Department: ,Room: Patient's name: ,Sex: ,Age: Nationality: ,Occupation: Address: Referral from: Chief Complaint Main symptoms that the patient comes to see a doctor History of present illness(HPI) Location: ,Severity: ,Duration: When Progressing, regressing, steady constant, intermittent, frequency aggravating, alleviating, Associated factor Medications Allergic Currence medication(CM) Past of medical history(PMH) Medications/Vitamins/Herbal(-/-/-) Allergies Operations/Hospitalizations/Blood transfusions(-/-/-) When?How many?Type? Adult patient: DM/HTN/MI/Stroke/Peptic ulcer/Asthma/Emphysema/Thyroid/Liver/Kidney/ Bleeding/Cancer/TB/Hepatitis/STD ask about routine health maintenance Pediatric patient: Past Surgical and OBGYN history Past surgical history: Type, date, pathology OBGYN history(If female): Menarche, Menstrual cycle, Paragravida, abortion Urogenital tract:...
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