全科醫(yī)療健康檔案

全科醫(yī)療健康檔案（SOAP病歷）檔案號(hào)：

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聯(lián)系電話：主觀資料（S）主訴：_________________________________________________________________________現(xiàn)病史：___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________既往史：_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________藥物過敏史：__________________________________________________________________________________________________________________________________________________婚育史：_______________________________________________________________________家族史：關(guān)系糖尿病高血壓腦卒中冠心病肝炎精神病先天畸形父親母親兄弟姐妹配偶子女生活習(xí)慣：吸煙：_______飲酒：_________鍛煉：_________飲食：________________客觀資料（O）身高：_______m體重：_______kgBMI:___________kg/m2體溫：_______℃血壓：_______/_______mmHg脈搏：_______/min一般情況：______________________________________________________________________皮膚：__________________________________________________________________________頭：___________________________________________________________________________眼：結(jié)膜_____________________________鞏膜_____________________________________瞳孔_______________________________________________________________________眼底_______________________________________________________________________耳：__________________________________________________________________________________________________________________________________________________________鼻：__________________________________________________________________________________________________________________________________________________________口腔：舌_______________________________________________________________________牙齒_____________________________________________________________________咽_______________________________________________________________________扁桃體______________________________________________________________________________________________________________________________________________頸部：氣管_____________________________________________________________________血管_____________________________________________________________________甲狀腺______________________________________________________________________________________________________________________________________________淋巴結(jié)____________________________________________________________________胸部：__________________________________________________________________________胸廓:_____________________________________________________________________________________________________________________________________________乳腺：___________________________________________________________________肺部：_____________________________________________________________________________________________________________________________________________心臟：____________________________________________________________________________________________________________________________________________腹部：_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________脊柱：________________________________________________________________________________________________________________________________________________________四肢：________________________________________________________________________________________________________________________________________________________神經(jīng)系統(tǒng)：____________________________________________________________________________________________________________________________________________________生殖系統(tǒng)：____________________________________________________________________________________________________________________________________________________直腸：_________________________________________________________________________實(shí)驗(yàn)室檢查及結(jié)果：___________________________________________________________________________________________________________________________________________________________________________________________________________________________輔助檢查及結(jié)果：______________________________________________________________________________________________________________________________________________其他檢查及結(jié)果：_______________________________________________________________評(píng)估（A）___________________________________________________________________________________________________________________________________________________________________________________________________________________________________處理計(jì)劃（P）診斷計(jì)劃：_____________________________________________________________________________________________________________________________________________________治療計(jì)劃：________________________________________________________________________________________________________________________________________________________________