一、主要調(diào)查項(xiàng)目：
1.主訴chief complaint：weakness, malaise, chills, fever, sleep, pain, headache, appetite, weight, stomach and bowels, nausea and vomiting, diarrhea, urine, genitalia, neuropsychiatric disorders, respiration, shortness of breath, bleeding or discharge, etc.
2.現(xiàn)癥歷present illness：onset(date, mode), duration before present entry, exciting cause and environmental influences, prodromal symptoms, general symptoms, course or progress( location, duration, severity, continuity, intermission, radiation, treatment), aggravating and alleviating factors, loss of weight, appetite and strength, sleep, bowel movement, frequency of urination, menstruation, etc.
3.既往歷past history：
1)former places of residence, previous stage of health( 健壯的robust，纖弱的delicate), experience with similar disease, immunity to infectious disease醫(yī)學(xué)全在.線提供
2)previous illness：麻疹measles, 腮腺炎mumps, 水痘chicken-pox, 百日咳pertussis, 流行性感冒influenza, 猩紅熱scarlet fever, 白喉diphtheria，傷寒typhoid fever, 支氣管炎bronchitis, 肺炎pneumonia，腦炎encephalitis,腦膜炎meningitis，破傷風(fēng)tetanus,小兒麻痺poliomyelitis,赤痢dysentery，霍亂cholera, 胸膜炎pleurisy,天花small-pox，瘧疾malaria,結(jié)核病tuberculosis，黃疸病jaundice，過敏性反應(yīng)allergy,etc
3)venereal disease：specific symptoms, signs, and the disease by name, treatment.
4)Accidents( date, any disability, sequelae), operation and hospitalization (date , procedure, name of hospital , physician, complications, bleeding tendency)
4.家族歷family history：family tendency, presence of hereditary disorders, cancer, tuberculosis, mental disorder and nervous affection, rheumatism, diabetes, hypertension, cerebral vascular accident, hemophilia, syphilis, tumor, epilespsy, allergy, contact with diseased individuals, relationship of patient’s childhood and adult life, age, health condition, and cause of death of parents, grandparents, self , spouse, siblings , or relatives.
5.個人歷personal history：
1)Social history：fears, metal status, education, financial condition, number of dependents, family harmony or fractious , hygienic condition at home
2)Marital history：duration of marriage, 1st or 2nd marriage, age and death of spouse and children , cause and age at time of death, number of children , pregnancies, 流產(chǎn)次數(shù)miscarriages, 死產(chǎn)數(shù) stillbirths
3)occupational history：duration of employment, past work, exact nature of work, exposure to occupational hazards, whether work is satisfactory or not.
4)Habits：alcohol, tobacco, narcotic, coffee, tea, appetite, food habits, regularity of meals, rapidity of eating , bowel movements, sleep, exercise, interests, etc.
6.系統(tǒng)檢查system review：
1)General：nutrition, fever, night sweats, tremor, weight gain or loss, weakness, allergy.
2)Skin：蕁蔴疹hives, rash, eczema
3)Head：trauma, headache, loss of hair
4)Eyes：vision, pain glasses diplopia.
5)Ears：pain, discharge, deafness, tinnitus.
6)Nose：obstruction, discharge, epistaxis, rhinitis.
7)Mouth：teeth, lips, gums, tongue, disturbance in taste.
8)Throat.：sore throat, tonsillitis, 膿性扁桃腺炎quinsy, dysphagia
9)Neck：adenitis, goiter , rigidity
10)Cardiorespiratory：palpitation, tachycardia, blood pressure, chest pain, dyspnea, cough , hemoptysis , seasonal cold, expectoration.
11)Gastrointestinal：appetite, nausea, vomiting, distress(before or after meals), melena, colic, jaundice, fullness, hernia, hemorrhoid, constipation, diarrhea, frequency of bowel movement , heartburn, idiosyncrasies, relation of symptoms to eating, type and quantity of food
12)Genito-urinary：dysuria, urinary frequency, dribbling , hematuria, pyuria, nocturia and volume, enuresis, incontinence, sores about external genitalia, symptoms suggestive of syphilis(mucous patches, falling hair), urethral discharge, exposure to venereal infection, obstetric history, catamenia(age of onset, date of last period, cycle and amount, periodicity , dysmenorrheal, menopause) leucorrhea, associated headache
13)Neuromuscular：神經(jīng)過敏nervousness, emotional stress, weakness, muscle or joint pains, convulsion, numbness, neuralgia, anesthesia, muscular atrophies or dysatrophies, deformities.
