История болезни № ______

(по журналу стационарных больных)

Клиника _______________________ Денник или станок № _______________

Диагноз (первоначальный) __________________________________________

Диагноз (при последующем наблюдении) _____________________________

Хозяйство или фамилия владельца____________________________________

Адрес ________________________________________Телефон ____________

Возраст________________________ Масть, окрас и приметы _____________

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Порода ___________Кличка, тавро, бирка № _______ Живой вес __________

Даты: поступления в клинику «__» ____20__г., выбытия из «__»____20__г.

Количество суток лечения в клинике __________________________________

Исход заболевания _________________________________________________

Куратор _____________________

Анамнез (Anamnesis)

(Anamnesis vitae) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(Anamnesis morbi) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Данные исследования - Status praesens Общее исследование

«_____»_________200__г.

Температура____________________Пульс_____________Дыхание_________

Гапитус___________________________________________________________

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Исследование кожи ________________________________________________________

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Исследование лимфоузлов ___________________________________________

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Исследование слизистых оболочек_____________________________________________

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Исследование отдельных систем

Система органов кровообращения _____________________________________________

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Система органов дыхания ____________________________________________________

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Система органов пищеварения ________________________________________________

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Система органов движения ___________________________________________________

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Нервная система ____________________________________________________________

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Исследование зоны патологического процесса – Status localis

(подробное описание клинических признаков патологического процесса)

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