US Medical Forms · 中文

病史表格

⚠ 这是参考翻译，帮助您了解典型表格内容。这不是官方文件。您的医疗提供者的实际表格可能有所不同——请务必签署提供者自己的版本。

When you receive this form 在初诊预约或与新医疗提供者建立医疗关系时。许多诊所会在就诊前邮寄或发送电子邮件，以便您有充裕时间在家填写。

What to bring or have ready 您已知的诊断和手术清单及大致日期；家族病史（如果知道）；以及任何可用的既往病历记录。

个人信息与主诉 / Personal Information and Chief Complaint

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Full name	全名	Your legal name as it appears on your ID or insurance card.	您在身份证或保险卡上的法定姓名。
Date of birth	出生日期	Used to verify your identity and match your records. Write in MM/DD/YYYY format if not pre-filled.	用于核实您的身份并匹配您的病历。如未预填，请使用月/日/年格式填写。
Reason for today's visit (chief complaint)	今日就诊原因（主诉）	Describe the main symptom or concern in your own words — for example, 'knee pain for 2 weeks' or 'annual physical.' Keep it brief; the provider will ask follow-up questions.	用自己的话描述主要症状或担忧，例如「膝盖疼痛两周」或「年度体检」。简短描述即可；医疗提供者会进一步询问。

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Known diagnoses (check all that apply)	已知诊断（勾选所有适用项）	Common options include diabetes, hypertension (high blood pressure), asthma, heart disease, cancer, thyroid disease, depression or anxiety, and arthritis. Check any you have been formally diagnosed with by a provider.	常见选项包括糖尿病、高血压、哮喘、心脏病、癌症、甲状腺疾病、抑郁症或焦虑症以及关节炎。勾选任何已由医生正式诊断的疾病。
Current medications	当前用药	List each prescription and over-the-counter medication you take regularly. Include the name and dose if known. A separate Medication and Allergy List form often captures this in more detail.	列出您定期服用的每种处方药和非处方药，包括名称和剂量（如知道的话）。单独的药物和过敏列表表格通常会更详细地记录这些信息。
Ongoing symptoms or concerns	持续症状或疑虑	Note any symptoms that have persisted for weeks or months, even if you are not sure of the cause. This helps the provider decide which areas to examine or test.	注明任何持续数周或数月的症状，即使您不确定原因。这有助于医疗提供者决定检查或测试哪些方面。

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Past surgeries	既往手术	List each surgery with the approximate year — for example, 'appendectomy, 2015.' If you have had no surgeries, write 'none.'	列出每次手术及大致年份，例如「阑尾切除术，2015年」。如果您从未做过手术，请写「无」。
Previous hospitalizations	既往住院情况	Include overnight hospital stays for any reason — illness, injury, or mental health — with the approximate year. Routine outpatient visits do not need to be listed here.	包括因任何原因（疾病、受伤或心理健康）的住院经历及大致年份。常规门诊就诊不需要在此列出。
Significant illnesses or injuries	重大疾病或受伤	Include serious illnesses such as a heart attack, stroke, or major infection that required extended care, even if they did not result in surgery or hospitalization.	包括严重疾病，如心脏病发作、中风或需要长期护理的重大感染，即使它们没有导致手术或住院治疗。

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Family history of heart disease, stroke, or cancer	家族心脏病、中风或癌症史	Note which relatives were affected — for example, 'mother, breast cancer' or 'father, heart attack at age 50.' Focus on parents, siblings, and grandparents. If you do not know, write 'unknown.'	注明哪些亲属受到影响，例如「母亲，乳腺癌」或「父亲，50岁时心脏病发作」。重点关注父母、兄弟姐妹和祖父母。如果不知道，请写「不详」。
Family history of diabetes or inherited conditions	家族糖尿病或遗传性疾病史	List conditions common in your family, such as type 2 diabetes, high cholesterol, kidney disease, or genetic disorders. Note which relative had the condition.	列出家族中常见的疾病，如2型糖尿病、高胆固醇、肾病或遗传性疾病。注明哪位亲属有该疾病。

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Smoking status	吸烟状况	Select: never smoked, former smoker (quit date if known), or current smoker (packs per day or type — cigarettes, e-cigarettes, cigars). Smoking affects many health conditions and medications.	选择：从不吸烟、曾经吸烟（如知道戒烟日期）或目前吸烟（每天吸几包，或注明类型——香烟、电子烟、雪茄）。吸烟会影响许多健康状况和药物。
Alcohol use	饮酒情况	Indicate: none, occasional (a few drinks per month), moderate (up to one drink per day), or heavy (more than one drink per day). Alcohol interacts with many medications and affects health screenings.	注明：不饮酒、偶尔饮酒（每月几次）、适量饮酒（每天最多一次）或大量饮酒（每天超过一次）。酒精与许多药物相互作用并影响健康筛查。
Exercise habits	锻炼习惯	Select: sedentary (little to no regular exercise), light (1–2 days per week), moderate (3–4 days per week), or vigorous (5 or more days per week). Note the type of activity if you wish.	选择：久坐（几乎不锻炼）、轻度（每周1-2天）、中度（每周3-4天）或高强度（每周5天或以上）。如果愿意，可注明活动类型。

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Last reviewed: September 2026