SUMY STATE UNIVERSITY
MEDICAL INSTITUTE
INTERNAL MEDICINE DEPARTMENT

The head of the department
Doctor of Medicine,
Professor : __________________________ Manager of the group
____________________

MEDICAL CARD

name, surname of the patient

_______________ age of the patient

Clinical diagnosis: basic diagnosis __________________________________________ __________________________________________
__________________________________________
Complication __________________________________________
__________________________________________
Concomitant disease __________________________________________ __________________________________________
__________________________________________

|Mark for the writing |Curator ____________________________ | |of the case history ______________ |The group __________, the course ______ | |Mark for the defense | | |of the case history ______________ | |

Sumy
GENERAL INFORMATION ABOUT PATIENT
Name _________________________________________________________________ Surname _______________________________________________________________ Date of birth ____________________________, age ___________________________ Home address __________________________________________________________ Preschool or school institution _____________________________________________ Date of admission to the hospital ___________________________________________ Institution which has directed patient to the hospital ____________________________ Pre-admission diagnosis __________________________________________________ ______________________________________________________________________ Patient’s department _____________________________________________________ I. COMPLAINTS

Main: ________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________

Additional: ____________________________________________________________

___________________________________________________________________________________________________ ______________________________________________________________________

II. ANAMNESIS OF THE DISEASE

The onset of disease acute, subacute, gradually (the necessary underline). The duration of the diseases is ______________. What preceded the disease (cooling, defects of nutrition, viruses infection, the contact with ill person, etc) ___________________________________

___________________________________________________________________________________________________ ______________________________________________________________________ The development of disease _______________________________________________ ______________________________________________________________________ ______________________________________________________________________ The result of previous additional methods of investigation (if they were presence) _______ ______________________________________________________________________ ______________________________________________________________________ The previous treatment (if it was presence): _____________________________________ ____________________________________________________________________________________________________________________________________________ The effect of previous treatment ____________________________________________ ______________________________________________________________________ The reason of hospitalization _______________________________________________ ______________________________________________________________________ III. ANAMNESIS VITAE

____________________________________________________________________________________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____________________________________________________________________________________________________________________________________________.

Allergological history
Presence of allergy symptoms _____________________________________________. The intolerance of products _____________________________________________, that accompanied with ___________________________________________________, The intolerance of medicament (drug) _______________________________________ that accompanied with ___________________________________________________. Prophylactic vaccinations _________________________________________________. ______________________________________________________________________ The nearest relatives have such chronic somatic illnesses ________________________ ____________________________________________________________________________________________________________________________________________, genetically illnesses ____________________________________________________, allergic reactions _______________________________________________________. Epidemiological history

The patient didn’t contact with patients wh...

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