全科医疗健康档案

全科医疗健康档案（SOAP病历）档案号：

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出生地：民族：

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联系电话：主观资料（S）主诉：_________________________________________________________________________现病史：___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________既往史：_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________药物过敏史：__________________________________________________________________________________________________________________________________________________婚育史：_______________________________________________________________________家族史：关系糖尿病高血压脑卒中冠心病肝炎精神病先天畸形父亲母亲兄弟姐妹配偶子女生活习惯：吸烟：_______饮酒：_________锻炼：_________饮食：________________客观资料（O）身高：_______m体重：_______kgBMI:___________kg/m2体温：_______℃血压：_______/_______mmHg脉搏：_______/min一般情况：______________________________________________________________________皮肤：__________________________________________________________________________头：___________________________________________________________________________眼：结膜_____________________________巩膜_____________________________________瞳孔_______________________________________________________________________眼底_______________________________________________________________________耳：__________________________________________________________________________________________________________________________________________________________鼻：__________________________________________________________________________________________________________________________________________________________口腔：舌_______________________________________________________________________牙齿_____________________________________________________________________咽_______________________________________________________________________扁桃体______________________________________________________________________________________________________________________________________________颈部：气管_____________________________________________________________________血管_____________________________________________________________________甲状腺______________________________________________________________________________________________________________________________________________淋巴结____________________________________________________________________胸部：__________________________________________________________________________胸廓:_____________________________________________________________________________________________________________________________________________乳腺：___________________________________________________________________肺部：_____________________________________________________________________________________________________________________________________________心脏：____________________________________________________________________________________________________________________________________________腹部：_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________脊柱：________________________________________________________________________________________________________________________________________________________四肢：________________________________________________________________________________________________________________________________________________________神经系统：____________________________________________________________________________________________________________________________________________________生殖系统：____________________________________________________________________________________________________________________________________________________直肠：_________________________________________________________________________实验室检查及结果：___________________________________________________________________________________________________________________________________________________________________________________________________________________________辅助检查及结果：______________________________________________________________________________________________________________________________________________其他检查及结果：_______________________________________________________________评估（A）___________________________________________________________________________________________________________________________________________________________________________________________________________________________________处理计划（P）诊断计划：_____________________________________________________________________________________________________________________________________________________治疗计划：________________________________________________________________________________________________________________________________________________________________