환자건강력 /Patient Health History 방문이유 / 무엇에대해이야기하고싶습니까?/Reason for Visit/What do you want to talk about: 1. 환자병력 /PATIENT HISTORY 다음중과거또는현재겪고있는것이있습니까?/Have you ever, or do you now have any of the following? 빈혈 /anemia 섭식장애 /eating problems 흑색종 /melanoma 식욕부진 /anorexia 우울증 /depression 월경문제 /menstrual problems 관절염 /arthritis 당뇨병 /diabetes 편두통 /migraines 천식 /asthma 간질또는발작 /epilepsy or seizures 성병 /sexually transmitted disease 암 /cancer 심장질환 /heart disease 갑상선문제 /thyroid problems 수두 /chicken pox 고혈압 / 저혈압 /high/low blood pressure 기타 ( 기재해주십시오 )/other, please list: 과거경험했던모든 ( 수술, 의료, 정신과 ) 입원및해당년도를기재해주십시오./Please list all hospitalizations you have had (surgical, medical, psychiatric) and the year: 2. 가족력 /FAMILY HISTORY 예인경우, 해당되는곳에모두체크표시하십시오./If yes, check all that apply: 유방암 /Breast Cancer 결장암 /Colon Cancer 당뇨병 /Diabetes 유전적장애 /Genetic Disorder 심장질환 /Heart Disease 고혈압 /High Blood Pressure 고콜레스테롤 /High Cholesterol 기타암 /Other Cancer 3. 건강위험요인평가 /HEALTH RISK ASSESSMENT 다음페이지로 /Go to Next Page 1/7 페이지 /Page 1 of 7 년 월 10 일 6
음주를하십니까?/Do you drink alcohol? 예인경우, 1 주일주량 ( 잔 )/If yes, # of drinks per week: 담배를피거나다른형태의담배를사용하십니까?/Do you smoke or use other forms of tobacco? 과거흡연자의경우, 담배를끊은날짜 /If former, quit date: 과거흡연자 /former 기분전환용약물 / 마약을사용한적이있습니까?/Have you ever used recreational/street drugs? 처방약을남용한적이있습니까?/Have you ever misused prescribed drugs? 규칙적으로운동하십니까?/Do you exercise regularly? 본인의식습관에만족하십니까?/Are you satisfied with your eating habits? 지난 2 주동안일을하는데거의관심이없거나즐거움이없었던적이얼마나됩니까?/Over the past two weeks, how often have you had little interest or pleasure in doing things? 답변은하나만선택하십시오./Select one response. 전혀없었음 t at all 여러날 /several days 하루의절반이상 /more than half of the days 거의매일 /nearly every day 지난 2 주동안얼마나자주기분이가라앉거나, 우울하거나절망적으로느꼈습니까?/Over the past two weeks, how often have you been down, depressed, or hopeless? 답변은하나만선택하십시오./Select one response. 전혀없었음 t at all 여러날 /several days 하루의절반이상 /more than half of the days 거의매일 /nearly every day 가족 / 중요한다른사람 ( 파트너 ) 에게영향을미치는중요한문제가있습니까?/Are there any significant issues affecting family/significant others? 예인경우, 설명해주십시오./If yes, please explain: 귀하의진료와관련해종교적 / 문화적으로고려해야할사항이있습니까?/Are there any religious/cultural considerations regarding your care? 예인경우, 설명해주십시오./If yes, please explain: 성병에대해궁금한점이있습니까?/Do you have any questions about sexually transmitted diseases? 성병에대한검사를받기를원하십니까?/Would you like to be tested for sexually transmitted diseases? 캠퍼스및 / 또는가정에서안전하지못하다고느끼는일을경험하고있습니까?/Are you having any experiences on campus and/or at home that make you feel unsafe? 4. 알레르기및예방접종 /ALLERGIES and IMMUNIZATIONS Follow My Health 계정이있으며해당계정에있는정보를검토하고정확한지확인한경우가아니면섹션 4 A-B 를작성해야합니다./Please complete section 4 A-B unless you have a Follow My Health account and you have reviewed and verified the accuracy of the information in your account. Follow My Health 에대한자세한정보는 medical.mit.edu/fmh 에서확인할수있습니다./For more information on Follow My Health, please visit medical.mit.edu/fmh 2/7 페이지 /Page 2 of 7
A. 알레르기 /Allergies 알레르기가있는약이있습니까?/Do you have any allergies to medications? 예인경우, 그약 ( 들 ) 과반응을기재해주십시오./If yes, please list medication(s) and reaction: B. 예방접종 /Immunizations * 예약방문시모든예뱡접종정보를지참해주시기바랍니다./Please bring any immunization information with you to your appointment. C. 약 /Medications * 예약방문시모든복용약정보를지참해주시기바랍니다./Please bring any medication information with you to your appointment. 5. 학습요구도평가 /LEARNING NEEDS ASSESSMENT 다음중해당되는것이있습니까?/Do you have any of the following: 학습장애?/Learning disabilities? 시력한계?/Visual limitations? 청력한계?/Hearing limitations? 예인경우, 설명해주십시오./If yes, please explain: 3/7 페이지 /Page 3 of 7
6. 체계검토 /REVIEW OF SYSTEMS 다음중현재경험하고있는것이있습니까?/Are you currently experiencing any of the following...? a. 일반 /General 피로 /Fatigue 4/7 페이지 /Page 4 of 7 수면장애 /Trouble sleeping 체중변화 /Weight changes 쇠약 /Weakness 발열 /Fever 통증, 0 ~ 10 까지의척도에서평가 (0 = 통증없음, 10 = 최악의통증 )/Pain, rated on a scale from 0-10 (0 = no pain, 10 = worst pain): b. 기능평가 /Functional assessment 건강상다음중제한되는활동이있습니까?/Is your health limited in any of the following activities: 직장업무?/Work? 일상의잡무?/Daily chores? 적당한운동?/ Moderate exercise? 격렬한운동?/ Vigorous exercise? / no / no 예인경우, 설명해주십시오./If yes, please explain: c. 피부 /Skin 발진 /Rashes 가려움증 /Itching 피부색변화 /Color changes d. 머리 /Head e. 귀 /Ears 두통 /Headache 두부외상 /Head injury 종괴 /Lumps 건조 /Dryness 귀통증 /Earache 이명 /Tinnitus 분비물 /Drainage 청력감소 /Decreased hearing f. 눈 /Eyes 시력 /Vision 광시증 /Flashing lights 백내장 /Cataracts 안경 / 콘택트렌즈 /Glasses/contacts 머리및손발톱변화 /Hair and nail changes 시야흐림또는복시 /Blurry or double vision 통증 /Pain 소반점 /Specks 충혈 /Redness 녹내장 /Glaucoma 마지막시력검사일 /Last eye exam: g. 코 /Nose 가려움 /Itching h. 인후 / 구강 /Throat/Mouth 치아 /Teeth 출혈 /Bleeding i. 목 /Neck 코피 /Nosebleeds 혀통증 /Sore tongue 인후염 /Sore throat 코막힘 /Stuffiness 콧물 /Discharge 건초열 /Hay fever 아구창 /Thrush 잇몸 /Gums 입안건조 /Dry mouth 의치 /Dentures 쉰소리 /Hoarse ness 부비동통증 /Sinus pain 낫지않는궤양 /Non-healing sores 마지막치과검사일 /Last dental exam:
종괴 /Lumps 통증 /Pain 부어오른샘 /Swollen glands j. 유방 /Breasts 종괴 /Lumps k. 호흡기 /Respiratory 분비물 /Discharge 모유수유 /Breast feeding 의료기록번호 /MRN: 경직 /Stiffness 통증 /Pain 기침 /Cough 피를토함 /Coughing up blood 쌕쌕거림 /Wheezing 점액 /Mucus 호흡곤란 /Shortness of breath 동통성호흡 /Painful breathing l. 심혈관 /Cardiovascular 흉통또는불편감 /Chest pain or discomfort 호흡곤란으로잠에서갑자기깨어남 /Sudden awakening from sleep with shortness of breath 누웠을때호흡곤란 /Difficulty breathing lying down 활동으로인한호흡곤란 /Shortness of breath with activity 압박감 /Tightness 부종 /Swelling 두근거림 /Pal pitations 5/7 페이지 /Page 5 of 7
m. 위장 /Gastrointestinal 설사 /Diarrhea 속쓰림 /Heartburn n. 비뇨기 /Urinary 빈뇨 /Increased frequency 변비 /Constipation 직장출혈 /Rectal bleeding 식욕변화 /Change in appetite 의료기록번호 /MRN: 구역 /Nausea 연하곤란 /Swallowing difficulties 배뇨조절기능상실 /Loss of control of urine 황색눈이나피부 ( 황달 )/ Yellow eyes or skin (jaundice) 배변습관의변화 /Change in bowel habits 소변강도변화 /Change in urinary strength 절박증 /Urgency 작열감또는통증 /Burning or pain 소변에혈액이섞여나옴 ( 혈뇨 )/Blood in urine (hematuria) o. 생식기 /Genital 남성 /Male 탈장 /Hernia 성교시통증 /Pain with sex 생식기궤양 /Genital sores 성병 /STD's: 여성 /Female 성교시통증 /Pain with sex 일과성열감 /Hot flashes 성병 /STD's: p. 혈관 /Vascular 걸을때종아리통증 /Calf pain with walking q. 근골격 /Musculoskeletal 질가려움증또는발진 /Vaginal itching or rash 음경분비물 /Penile discharge 음낭덩이또는통증 /Scrotal masses or pain 질건조증 /Vaginal dryness 마지막월경일 /Last menstrual period: 다리경련 /Leg cramping 요통 /Back pain 경직 /Stiffness 관절부종 /Swelling of joints r. 신경 /Neurologic 어지러움 /Dizziness 외상 /Trauma 쇠약 /Weakness 무감각 /Numbness 떨림 /Tremor 관절발적 /Redness of joints 발작 /Seizure 발기부전 /Erectile dysfunction 질분비물 /Vaginal discharge 생식기궤양 /Genital sores 저림 /Tingling 근육통또는관절통 /Muscle or joint pain 실신 /Fainting s. 혈액학 /Hematologic 멍이쉽게듬 /Ease of bruising 잦은출혈 /Ease of bleeding t. 내분비 /Endocrine 열또는한랭불내성 /Heat or cold intolerance 빈뇨 /Frequent urination 발한 /Sweating 갈증 /Thirst 식욕변화 /Change in appetite 6/7 페이지 /Page 6 of 7
의료기록번호 /MRN: u. 정신과 /Psychiatric 스트레스 /Stress 기억력감퇴 /Memory loss 신경과민증 /Nervousness 우울증 /Depression MIT 커뮤니티에있는모든사람의건강과웰니스는 MIT Medical 에중요합니다. MIT Medical 은다음사항을권장합니다./The health and wellness of everyone in the MIT community is important to us at MIT Medical. We recommend the following:we recommend the following: STD 및의도하지않은임신의위험을줄이기위해성행위시콘돔사용 /Condom use during sexual activity to reduce the risk of STDs and unintended pregnancy 부상이나사망의위험을줄이기위해매사추세츠주법에따라자동차안전벨트착용 /Use of automobile safety belts to reduce the risk of injury or death, which is the law in Massachusetts 자전거, 롤러블레이드, 스케이트보드등을타는동안부상의위험을줄이기위해헬멧사용 /Use of helmets while bicycling, rollerblading, skate boarding, etc. to reduce the risk of injury 화재로인한부상이나손상의위험을줄이기위해가정내연기감지기설치 /Home smoke detectors to reduce the risk of injury or damage from a fire 자신과자녀를위해야외에서햇빛에나갈때는 SPF 15 이상의자외선차단제사용 /Use of sunscreen SPF 15 or higher for you and your children when in the outdoor sun 환자이름 ( 정자체 )/Patient Name (PRINT): 환자서명 /Patient Signature: 의료제공자서명 /Provider Signature: 생년월일 /DOB: 날짜 /Date: 날짜 /Date: 7/7 페이지 /Page 7 of 7 *