日期:

姓:
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名:
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地址:
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出生日期:
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主訴:
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健康保險:
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手術及住院治療史:
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藥物及飲食服用史:
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病史:
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胃口:
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口渴:
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腸蠕動:
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小便:
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排汗:
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月經史:
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呼吸次數:
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臟腑器官:
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神志:
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睡眠:
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氣候感覺:
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感覺器官:
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疼痛(位置及性質):
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脈象:
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舌苔:
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