MEDICAL CARD

name, surname of the patient

_______________ age of the patient

Clinical diagnosis: basic diagnosis __________________________________________
__________________________________________

__________________________________________

Complication __________________________________________

__________________________________________

Concomitant disease __________________________________________

__________________________________________

__________________________________________

Sumy

GENERAL INFORMATION ABOUT PATIENT

Name _________________________________________________________________

Surname _______________________________________________________________

Date of birth ____________________________, age ___________________________

Home address __________________________________________________________

Preschool or school institution _____________________________________________

Date of admission to the hospital ___________________________________________

Institution which has directed patient to the hospital ____________________________

Pre-admission diagnosis __________________________________________________

______________________________________________________________________

Patient’s department _____________________________________________________

I. COMPLAINTS

Main: ________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Additional: ____________________________________________________________

___________________________________________________________________________________________________

______________________________________________________________________

II. ANAMNESIS OF THE DISEASE

The onset of disease acute, subacute, gradually (the necessary underline). The duration of the diseases is ______________. What preceded the disease (cooling, defects of nutrition, viruses infection, the contact with ill person, etc) ___________________________________

___________________________________________________________________________________________________

______________________________________________________________________

The development of disease _______________________________________________

______________________________________________________________________

______________________________________________________________________

The result of previous additional methods of investigation (if they were presence) _______

______________________________________________________________________

______________________________________________________________________

The previous treatment (if it was presence): _____________________________________

____________________________________________________________________________________________________________________________________________

The effect of previous treatment ____________________________________________

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The reason of hospitalization _______________________________________________

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III. ANAMNESIS VITAE

For children till 3 years

The child from ____ (behind the account) pregnancy, _____ delivery. Age of the mother during the given pregnancy. The pregnancy proceeded (with, without) gestosis in ___ trimester, on a background (without) of the extragenital pathology ___________

________________________, or inflectional diseases ___________________________

___________________________________ or somatic illness ____________________

________________________________________________ in _______ trimester.

The mother used such medicines (to specify the trimester) _______________________________

______________________________________________________________________

Harmful habits at the mother: ______________________________________________,

at the father ___________________________________________________________.

Conditions of work of the mother during pregnancy ____________________________

Conditions of life of the mother during pregnancy ______________________________

Delivery at timed or premature (the necessary underline), in ___ weeks of gestation. Labor via vaginal way or by caesarean section, with (without) medicamental stimulation _______________________ (the necessary underline). The child was mature or immature, according Apgar’s score _____ points at first min. and ____ points at 5^th min. Birth weight was ______ g, length of the body was ___ сm, head circumference was ___ сm, chest circumference was ___ cm. The umbilical stump (residual cord) has fallen off in ___ days. After the stump has fallen off, the state of cord base was dry, or was weeping during __________ weeks.

The child discharged from maternity department on ____ day (when it was more than 5-6 days, specify the cause of delay) __________________________________________.

During the firs year the child was at ___________________ feeding. The reason of artificial feeding was ____________________________________________________. Mother used to such ______________________________________________________

Formulas. The term of introduction of fruit juice __________, fruit puree ______, egg yolk __________, cottage cheese ___________, meat ____________. The first addition food was __________________ at _______ mo. The second addition food was _______ ____________ at _____ mo. The third addition food was _____________ at _____ mo.

The dynamics of body weight ______________________________________________ ______________________________________________________________________. Dynamics of body length _________________________________________________

______________________________________________________________________. Dynamics of head circumference __________________________________________. Dynamics of chest circumference ___________________________________________. The psychomotor development of the child ___________________________________

____________________________________________________________________________________________________________________________________________.

For all children irrespective of age

The child had such diseases (before admission) ________________________________

______________________________________________________________________

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Housing conditions of the child is satisfactory or not satisfactory (the necessary underline and explain why) __________________________________________________________.

Character of nutrition before present disease (character of meal, schedule of feeding) __
____________________________________________________________________________________________________________________________________________.

Allergological history

Presence of allergy symptoms _____________________________________________. The intolerance of products _____________________________________________, that accompanied with ___________________________________________________, The intolerance of medicament (drug) _______________________________________

that accompanied with ___________________________________________________.

Prophylactic vaccinations _________________________________________________.

______________________________________________________________________

The nearest relatives have such chronic somatic illnesses ________________________

____________________________________________________________________________________________________________________________________________, genetically illnesses ____________________________________________________,

allergic reactions _______________________________________________________.

Epidemiological history

The child didn’t contact with patients who suffered with inflectional diseases last 3 weeks. The symptoms of diarrhea were _______________ during last three days.

Genetical history

The data about siblings is collecting in everyone separately (How many children were at the family? How many children had died? What cause of death? What was physical and mental development? What diseases have had the child? How old were the parents at the moment of birth of the child?

Especial attention is deserved with the following practical moments:

1. Age of parents.

3. Nationality of parents.

4. Residence of the family.

5. Parents occupation.

6. Presence of chronic diseases at the relatives (beginning of disease, the clinical features of the diseases). For the relatives, who had died, indicate the cause of death and age of the person.

To make the pedigree of the patient, using common symbols:

	Healthy woman   Healthy man
	Proband
	Sex unknown
	Dead
	Abortion
	Medical abortion   Still-birth
	Marriage
	Consanguineous marriage
	Repeated marriage
	Unmarriage
	Sibling
	Monozygotic twins
	Dizygotic twins
	No known pregnancy
	Sterility
	Known heterozygous person
	Carrier female
	Pregnancy in progress
	Affected person

Summery: ______________________________________________________________

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Date: 2015-01-02; view: 1083