The present medical history of admission medical records is mainly based on the chief complaint, and the occurrence, development, diagnosis and treatment process of the disease are inquired in detail, focusing on: 1, onset: onset time, place, cause, inducement and urgency. 2. Occurrence and development of main symptoms: describe in detail the occurrence sequence of main symptoms until admission, including the nature, location, course, duration, mitigating or aggravating factors of symptoms, etc. 3. Accompanying symptoms: pay attention to the relationship between accompanying symptoms and main symptoms, as well as their occurrence time, characteristics and evolution. Negative symptoms related to differential diagnosis should also be recorded. 4. Diagnosis and treatment process: when and where to see a doctor, what disease was diagnosed, what important tests were made, and what was the result; What treatment have you received and how effective it is? 5. General situation: briefly record the changes of spirit, appetite, sleep and defecation since the onset. Past history mainly records the period from birth to onset. Those unrelated to the current medical history can be simplified, including: 1. General health in the past: sick or weak? What about the labor force? 2. History of infectious diseases, endemic diseases and parasitic diseases: record the disease name, onset date, course of disease, symptoms, treatment, complications and sequelae one by one. 3. Vaccination and contact history of infectious diseases: date and type of vaccination. If you suspect that the patient may be an infectious disease, you should ask and record in detail whether you have had contact with the same patient. 4. History of trauma and surgery: time, process and consequences. 5. Allergy history: history of allergies and allergic diseases related to drugs, food or special substances. 6. System review: Ask questions one by one according to the basic contents listed in the following system. If there is a positive finding, the occurrence time, course of disease, treatment and effect should be explained in detail. Every patient's self-reported illness name should be quoted. (1) Five senses: photophobia, eye pain, tinnitus, pus discharge, epistaxis, nasal congestion, toothache, gingival bleeding, sore throat, hoarseness, etc. (2) Respiratory system: chronic cough, expectoration, hemoptysis, chest pain, asthma, night sweats, fever, etc. (3) circulatory system: fatigue, palpitation, shortness of breath, cyanosis, edema, chest tightness, chest pain, hypertension, etc. (4) Digestive system: nausea, vomiting, hematemesis, abdominal pain, diarrhea, acid regurgitation, belching, jaundice, bloody stool, etc. (5) Urogenital system: low back pain, dysuria, frequent micturition, urgency, hematuria, pyuria, dysuria, frequent micturition at night, pudendal itching and ulceration. (6) Blood system: gingival bleeding, nosebleed, petechiae, purpura, hematoma, lymphadenopathy, etc. (7) Endocrine and metabolic system: fear of cold, heat, overeating, emaciation, excessive drinking and polyuria. Hair loss, decreased libido. (8) Bone and joint system: redness, pain, deformity, fistula, limited activity, etc. (9) Neuropsychiatric system: convulsion, paralysis, convulsion, coma, insanity, etc.