Including: name, gender, age, native place, birthplace, nationality, marriage, address, work unit, occupation, date of admission, date of recording, medical history presenter and reliability, etc. If the person presenting the medical history is not himself, his relationship with the patient should be indicated. When recording age, you should fill in the actual age, and you can't use "son" or "success" instead, because age itself has diagnostic reference significance.

(2) Chief complaint

Patients feel the most important pain or the most obvious symptoms and signs, which is the most important reason for seeing a doctor. The chief complaint should be concise, summarized in one or two sentences, and indicate the time from onset to treatment.

(3) Current medical history

The main part of medical history, including the whole process of disease occurrence, development and evolution, is the key content in consultation. Mainly includes the following aspects:

1. onset (priority) and onset time.

2. The characteristics of main symptoms, including location, radiation area, nature, attack frequency, duration, intensity, aggravating or mitigating factors.

3. Causes and incentives.

4. The development and evolution of the disease (recorded in chronological order, including the development of main symptoms and other related symptoms).

5. Accompanying symptoms.

6. Diagnosis and treatment (drugs, dosage, curative effect, etc. ).

7. General conditions since the onset (mental state, appetite, weight change, sleep and defecation, etc. ).

8. Induce, summarize and re-verify.

9. Ask questions about the past history in interlanguage.

(4) Past history

Also known as "past tense". Including:

1. The patient's past health status.

2. Past diseases (including various infectious diseases), especially the disease history closely related to the present medical history. For example, patients with coronary atherosclerotic heart disease should ask whether they had hypertension or diabetes in the past. Care should be taken not to confuse the description with the current medical history.

3. History of trauma, surgery, accidents and vaccination.

4. Allergy history (to drugs, food and environmental factors).

5. The main infectious diseases and endemic diseases in the living or living area should also be recorded in the past history.

6. The recording sequence is generally arranged in chronological order.

(5) Personal history

Personal experiences related to health and illness. Including:

1. Social experience includes place of birth, place of residence and time of residence (especially epidemic areas and epidemic areas), education level, economic life and hobbies.

2. Occupation and working conditions include work type, working environment, exposure to industrial poisons and time.

3. Habits and hobbies Life and hygiene habits, the regularity and quality of diet, tobacco and alcohol hobbies and intake, etc.

4. Have you ever had unclean sexual intercourse, gonorrhea, condyloma acuminatum, chancre, etc.

(6) Family history

Refers to the health status of related members of the patient's family, including:

1. Parents' age and health status (including grandparents in pediatrics).

2. The age and health status of the spouse.

3. Age and health of brothers and sisters.

4. Children's age and health.

5. Is there any disease in the family that is the same as the patient, and is there any disease related to heredity, such as albinism, hemophilia, congenital spherocytosis, diabetes, familial hypothyroidism, psychosis, etc. For the immediate family members who have died, ask the cause of death and age. The family history of some hereditary diseases should also include some non-immediate relatives.