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I. HÀNH CHÍNH

Họ và tên: ..................................................................................................

Tuổi: ........................................................................... Giới:……………..

Địa chỉ: ........................................................................................................

Số điện thoại:...............................................................................................

Nghề nghiệp: ...............................................................................................

Ngày nhập viện: .........................................................................................

Mã BN: ......................................................................................................

Ngày ra viện: ..............................................................................................

Chiều cao:……….cm Cân nặng:………..kg

II. THĂM KHÁM BỆNH NHÂN

1. Lý do vào viện: ......................................................................................

.....................................................................................................................

.....................................................................................................................

.....................................................................................................................

Thời gian xuất hiện triệu chứng đến lúc nhập viện:……….giờ.

2. Tiền sử:

- Đái tháo đường: ........................................................................................

- Tăng huyết áp: ..........................................................................................

- Bệnh lý tiết niệu:.......................................................................................

- Khác: .........................................................................................................

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