I. Passport part:
Full name _________________________________________________________
Sex _____________________ Age ____________________________
Nationality_________________________________________________
Marital status_____________________________________________________
Address____________________________________________________________________________________________________________
Profession____________________________________________________________________________________________________________
Education_________Date of admission to the clinic (year, month, day) __________________________________________________________
Diagnosis of the sending hospital_______________________________
Initial diagnosis ____________________________________________
Clinic diagnosis_____________________________________________
II. Main complaints of the patient: (yes) (no)
__________________________________________________________
(details of the main complaints, general complaints, accompanying complaints)
____________________________________________________________________________________________________________________
III. Anamnesis morbi:
Anamnesis of the pathological process “pp” must reflect the origin of “pp” and the dynamic of its development from the beginning of “pp” till present time. It is necessary to find out the health of patient till the beginning of “pp”. How “pp” began (acute or gradually) and what a patient relates “pp” with.
Try to find out causes of “pp”, first manifestations and further course in the chronological sequence. Character of the beginning “pp” (suddenly, acute attack, appear gradually, unnoticed or no opinion). Represent the appearance of relapsesor how often exacerbations are happened, (suddenly, acute attack, gradual exacerbation, unnoticed exacerbation); if the exacerbations develop gradually, specify their duration (till 3 days, till one week, till 2-3 weeks, more than 3 weeks, 2-3- months, more than 3 months), in which season of the year exacerbations are often shown (winter, spring, summer, autumn or any season); whether exacerbation of “pp” connected with changes of weather, the cold, the quinsy, nervous depressions, trauma; to select the periods of remission, having indicated their duration. Install motives to hospitalization to the clinic (getting worse of condition, revision of diagnose, etc.), time of disability to work, where the patient has treated and the results of treatment. Which remedies helped and didn’t help, the findings of last laboratory and other examinations.
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