Dietary History and Habits

Patient had natural / artificial feeding at an early patient’s age.

Nutrition sufficed for living, did not, malnutrition, starvation or overeating.

Patient’s nutrition is balanced, includes enough amount of proteins, lipids and carbohydrates, vitamins.

Meals are regular, irregular.

Patient prefers sharp, salty, spicy food.

Patient has smoked since __________ year up to ___________ cigarettes a day, gave up smoking in __________.

Patient has drunk since __________ year up to ___________ ml of ___________, prefers __________.

Patient has never used narcotics or has never had any drug abuse.

Gynaecological History

menses (date of onset, interval, regularity, duration, amount of flow, date of the last period, dysmenorrhoea, menorrhagia, irregular bleeding)

pregnancies (number, pathology, toxaemia, labour complications, abortions, miscarriages)

use of contraceptives

gynaecologic diseases, operations

the climacteric period (from what age, its manifestation, vegetovascular disorders, age of coming on menopause).

Past Medical History

Patient was ill with _______________ in __________.

measles

whooping cough

chickenpox

scarlet fever

flu

diphtheria

malaria

typhoid fever

epidemic typhus

virus hepatites

jaundice

tuberculosis

AIDS

venereal disease

cancer

poisonings

injuries

operations

Allergological History

Patient had allergic reaction as (vasomotor rhinitis, nettle-rash, angioneurotic Quincke’s oedema, bronchiospasm, anaphylactic shock) on

medicines

foodstuff

domestic and other dust

hair of animals, feathers of birds, fur

pollen of plants

household and industrial chemical substances

temperature and other weather factors.

Patient had not any allergic reaction on foodstuff, medicines and chemical substances.

Sanitary-and-Epidemiological History

Patient lives in (flat, house, own, rented) of size _________________ with

lack of conveniences, home comfort.

Patient had, did not have contact with sick people (infectious, icteric, with febrile state, with intestinal disorders) and sick animals.

Patient had departure (during last 2-3 months before hospitalization) to _________________.

Patient’s family received guests from ____________________________.

Patient was vaccinated against ______________ in and had injections of _____________ within last _________ months.

Patient had blood tests for antibodies to HIV, virus hepatitis (B, C) in _____________.

Ecological History

Patient’s residence is situated in the region without or with the industrial enterprises (thermal power plant, nuclear power plant and others) ___________________, with environmental pollution (air, ground, reservoirs) of hazardous, nuclear, radioactive and toxic wastes.

Дата добавления: 2015-11-14