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2025-04-23 13:27:25 +08:00
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<div id="_page" style="margin: 0px auto; background: rgb(255, 255, 255); width: 210mm; min-height: 297mm; transform: scale(1, 1); transform-origin: 50% 0px 0px;" pagekind="A4" direct="portrait"><div id="_header" style="min-height: 0.65cm; padding-left: 0.65cm; padding-right: 0.65cm; padding-top: 0.65cm; position: relative; outline: none;" contenteditable="false" class="">
<div style="text-align: center; ">&nbsp;</div>
<div style="text-align: center;font-size: 15px;"><span>姓名：</span>
<field tabindex="0" id="name" type="Text" contenteditable="true" class="input blank" title="姓名" value="姓名" name="name" data-code="" data-expression="" multiline="false" validate="false" format="" style="display: inline-block; min-width: 60px;">姓名</field>
<span>&nbsp;科室：</span>
<field tabindex="0" id="department" type="Text" contenteditable="true" class="input blank" title="科室" value="科室" name="department" data-code="" data-expression="" multiline="false" validate="false" format="" style="display: inline-block; min-width: 60px;">科室</field><span>&nbsp;床号：</span>
<field tabindex="0" id="bed_number" type="Text" contenteditable="true" class="input blank" title="床号" value="床号" name="bed_number" data-code="" data-expression="" multiline="false" validate="false" format="" style="display: inline-block; min-width: 60px;">床号</field><span title="" contenteditable="false">&nbsp;住院号：</span>
<field tabindex="0" id="admission_number" type="Text" contenteditable="true" class="input blank" title="住院号" value="文本输入域" name="admission_number" data-code="" data-expression="" multiline="false" validate="false" format="" style="display: inline-block; min-width: 60px;">住院号</field><span>&nbsp;病案号：</span>
<field tabindex="0" id="medical_record_number" type="Text" contenteditable="true" class="input blank" title="病案号" value="文本输入域" name="medical_record_number" data-code="" data-expression="" multiline="false" validate="false" format="" style="display: inline-block; min-width: 60px;">病案号</field>&nbsp;
</div>
</div><div id="_body" style="min-height: calc(1024.25px); padding-left: 0.65cm; padding-right: 0.65cm;" contenteditable="false" class=""><div class="Section0" style=""><p class="MsoNormal" style="margin-top:10.2500pt;margin-left:213.2000pt;mso-outline-level:1;"><span style="letter-spacing: 0.9pt; font-weight: bold; font-size: 16pt;">抑郁焦虑表</span></p><table class="16" id="" title="" data-field="" style="border-width: 1px; border-color: rgb(0, 0, 0);"><colgroup><col style="width: 421px;"><col style="width: 304px;"></colgroup><tbody style=""><tr style="height: 72.8pt"><td colspan="2" class=""><p class="15" style="margin-top: 1pt; margin-left: 26.1pt; line-height: 1.5;"><span style="letter-spacing: 0.266667px; font-size: 10.5pt;">1）我对以往感兴趣的事情还是有兴趣</span></p><p class="15" style="margin-left:24.7500pt;"><group type="radio" id="radio0" style="font-size: 10.5pt;"><input type="radio" id="radio0__0" name="radio0" value="0" checked="true"><label for="radio0__0">肯定一样——0分</label><br><input type="radio" id="radio0__1" name="radio0" value="1" style=""><label for="radio0__1">不像以前那样——1分</label><br><input type="radio" id="radio0__2" name="radio0" value="2"><label for="radio0__2">只有一点——2分</label><br><input type="radio" id="radio0__3" name="radio0" value="3"><label for="radio0__3">基本上没有了——3分</label><br></group><br></p></td></tr><tr style="height:72.5000pt"><td colspan="2" class="" style="border-color: rgb(0, 0, 0)"><p class="15" style="margin-top:1.5500pt;margin-left:25.5000pt;line-height:15.6500pt;
mso-line-height-rule:exactly;"><span style="font-size: 12px; letter-spacing: 0.333333px;">2</span><span style="letter-spacing: 0.333333px; font-size: 10.5pt;">）我能够哈哈大笑，并看到事物好的一面</span></p><p class="15" style="margin-left:24.7500pt;"><group type="radio" id="radio1" style="font-size: 10.5pt;"><input type="radio" id="radio1__0" name="radio1" value="0" checked="true"><label for="radio1__0">我经常这样——0分</label><br><input type="radio" id="radio1__1" name="radio1" value="1"><label for="radio1__1">现在已经不太这样了——1分</label><br><input type="radio" id="radio1__2" name="radio1" value="2"><label for="radio1__2">现在肯定是不太多了——2分</label><br><input type="radio" id="radio1__3" name="radio1" value="3"><label for="radio1__3">根本没有——3分</label><br></group><br></p></td></tr><tr style="height: 72.55pt;"><td colspan="2" class="" style="border-color: rgb(0, 0, 0);"><p class="15" style="margin-top:2.2500pt;margin-left:25.6000pt;"><span style="letter-spacing: 0.15pt; font-size: 9pt;">3</span><span style="letter-spacing: 0.15pt; font-size: 10.5pt;">）我感到愉快</span></p><p class="15" style="margin-top: 5.2pt; margin-left: 24.75pt; line-height: 15.7pt;"><span style="letter-spacing: -0.65pt; position: relative; top: -5pt;"><group type="radio" id="radio2" style="font-size: 10.5pt;"><input type="radio" id="radio2__0" name="radio2" value="0" checked="true"><label for="radio2__0">大多数时间——0分</label><br><input type="radio" id="radio2__1" name="radio2" value="1"><label for="radio2__1">有时——1分</label><br><input type="radio" id="radio2__2" name="radio2" value="2"><label for="radio2__2">并不经常——2分</label><br><input type="radio" id="radio2__3" name="radio2" value="3"><label for="radio2__3">根本没有——3分</label><br></group><br></span></p></td></tr><tr style="height: 72.55pt;"><td colspan="2" class="" style="border-color: rgb(0, 0, 0)"><p class="15" style="margin-top: 3.1pt; margin-left: 25.35pt; line-height: 1.5;"><span style="letter-spacing: 0.25pt; font-size: 9pt;">4</span><span style="font-size: 10.5pt; line-height: 1.5;"><span style="letter-spacing: 0.25pt;">）我对自己的仪容失去兴趣</span><o:p></o:p></span></p><p class="15" style="margin-top: 5.2pt; margin-left: 24.75pt; line-height: 1.5;"><span style="letter-spacing: -0.85pt; position: relative; top: -5pt; line-height: 1.5;"><group type="radio" id="radio3" style="font-size: 10.5pt; line-height: 1.5;"><input type="radio" id="radio30" name="radio3" value="0" checked="true"><label for="radio30">我仍然像以往一样关心——0分</label><br><input type="radio" id="radio31" name="radio3" value="1"><label for="radio31">我可能不是非常关心——1分</label><br><input type="radio" id="radio32" name="radio3" value="2"><label for="radio32">并不像我应该做的那样关心我——2分</label><br><input type="radio" id="radio33" name="radio3" value="3"><label for="radio33">肯定——3分</label><br></group><span style="font-size: 10.5pt; line-height: 1.5;"><br></span></span></p></td></tr><tr style="height: 72.55pt"><td colspan="2" class="" style="border-color: rgb(0, 0, 0)"><p class="15" style="margin-top: 3.8pt; margin-left: 25.6pt; line-height: 1.5;"><span style="font-size: 10.5pt; line-height: 1.5;"><span style="letter-spacing: 0.2pt; position: relative; top: -5pt;">5）我对一切都是乐观地向前看</span><o:p style=""></o:p></span></p><p class="15" style="margin-left: 24.75pt;"><span style="letter-spacing: -0.45pt;"><group type="radio" id="radio4" style="font-size: 10.5pt;"><input type="radio" id="radio40" name="radio4" value="0" checked="true"><label for="radio40">差不多是这样做——0分</label><br><input type="radio" id="radio41" name="radio4" value="1"><label for="radio41">并不完全是这样做的——1分</label><br><input type="radio" id="radio42" name="radio4" value="2"><label for="radio42">很少这样做——2分</label><br><input type="radio" id="radio43" name="radio4" value="3"><label for="radio43">几乎从不这样做——3分</label><br></group><br></span></p></td></tr><tr style="height: 108px"><td colspan="2" class="" style="border-color: rgb(0, 0, 0)"><p class="15" style="margin-top:4.5000pt;margin-left:25.5000pt;line-height:15.7500pt;
mso-line-height-rule:exactly;"><span style="font-size: 10.5pt;"><span style="letter-spacing: 0.25pt; position: relative; top: -5pt;">6）我好像感到情绪在渐渐低落</span><o:p></o:p></span></p><p class="15" style="margin-left:24.7500pt;"><span style="letter-spacing: -0.75pt;"><group type="radio" id="radio5" style="font-size: 10.5pt;"><input type="radio" id="radio5__0" name="radio5" value="0" checked="true"><label for="radio5__0">根本没有——0分</label><br><input type="radio" id="radio5__1" name="radio5" value="1"><label for="radio5__1">有时——1分</label><br><input type="radio" id="radio5__2" name="radio5" value="2"><label for="radio5__2">很经常——2分</label><br><input type="radio" id="radio5__3" name="radio5" value="3"><label for="radio5__3">几乎所有时间——3分</label><br></group><br></span></p></td></tr><tr style="height: 118px"><td colspan="2" class="" style="border-color: rgb(0, 0, 0);"><p class="15" style="margin-top:3.2500pt;margin-left:25.5000pt;"><span style="font-size: 10.5pt;"><span style="letter-spacing: 0.25pt;">7)我能欣赏一本好书或意向好的广播或电视节目</span><o:p></o:p></span></p><p class="15" style="margin-top: 5.25pt; margin-left: 24.75pt; line-height: 15.7pt;"><group type="radio" id="radio6" style="font-size: 10.5pt;"><input type="radio" id="radio6__0" name="radio6" value="0"><label for="radio6__0">常常如此——0分</label><br><input type="radio" id="radio6__1" name="radio6" value="1" checked="true"><label for="radio6__1">有时——1分</label><br><input type="radio" id="radio6__2" name="radio6" value="2"><label for="radio6__2">并非经常——2分</label><br><input type="radio" id="radio6__3" name="radio6" value="3"><label for="radio6__3">很少——3分</label><br></group><br></p></td></tr><tr style="height: 38px"><td class="" style="border-color: rgb(0, 0, 0)"><p class="15" style="margin-top:9.5000pt;margin-left:25.4000pt;"><span style="letter-spacing: 0.1pt; font-size: 10.5pt;"><font face="宋体" style="">抑郁得分（</font>0-21分）</span><span style="font-size: 9pt;"><o:p></o:p></span></p></td><td class=""><p class="MsoNormal" style=""><span style="font-family: Arial; font-size: 10.5pt;"><span>&nbsp;</span><field tabindex="0" id="total1" type="Text" contenteditable="true" class="input" title="文本输入域" value="1" name="total1" data-code="" data-expression="= radio0 + radio1 + radio2 + radio3 + radio4 + radio5 + radio6" multiline="false" validate="false" format="" style="display: inline-block; min-width: 100px; text-align: left;">1</field>&nbsp;</span></p></td></tr>
<tr style="height: 72.55pt"><td colspan="2" class="" style="border-color: rgb(0, 0, 0)"><p class="15" style="margin-top:1.7500pt;margin-left:26.1000pt;"><span style="letter-spacing: 0.1pt; font-size: 10.5pt;">1）我感到紧张（或痛苦）</span></p><p class="15" style="margin-top: 5.2pt; margin-left: 24.75pt; line-height: 15.7pt;"><span style="font-size: 10.5pt;"><group type="radio" id="radio7" style=""><input type="radio" id="radio7__0" name="radio7" value="0" checked="true"><label for="radio7__0">根本没有——0分</label><br><input type="radio" id="radio7__1" name="radio7" value="1"><label for="radio7__1">有时候——1分</label><br><input type="radio" id="radio7__2" name="radio7" value="2"><label for="radio7__2">大多时候——2分</label><br><input type="radio" id="radio7__3" name="radio7" value="3"><label for="radio7__3">几乎所有时候——3分</label><br></group><span>&nbsp;</span></span></p></td></tr><tr style="height: 138px;"><td colspan="2" class="" style="border-color: rgb(0, 0, 0);"><p class="15" style="margin-top:2.5000pt;margin-left:25.5000pt;line-height:15.7000pt;
mso-line-height-rule:exactly;"><span style="font-size: 10.5pt;"><span style="letter-spacing: 0.25pt; position: relative; top: -5pt;">2）我感到有点害怕好像预感到什么可怕的事情要发生</span><o:p></o:p></span></p><p class="15" style="margin-left: 24.75pt;"><group type="radio" id="radio8" style="font-size: 10.5pt;"><input type="radio" id="radio8__0" name="radio8" value="0" checked="true"><label for="radio8__0">根本没有——0分</label><br><input type="radio" id="radio8__1" name="radio8" value="1"><label for="radio8__1">有一点，但并不使我苦恼——1分</label><br><input type="radio" id="radio8__2" name="radio8" value="2"><label for="radio8__2">是有，不太严重——2分</label><br><input type="radio" id="radio8__3" name="radio8" value="3"><label for="radio8__3">非常肯定和十分严重——3分</label><br></group><br></p></td></tr><tr style="height: 127px;"><td colspan="2" class="" style="border-color: rgb(0, 0, 0);"><p class="MsoNormal" style="text-indent: 30px;"><span style="font-size: 10.5pt;">3）我的心中充满烦恼</span></p><p class="MsoNormal" style="margin-left: 24.75pt;"><span style="font-size: 10.5pt;"><group type="radio" id="radio9" style=""><input type="radio" id="radio90" name="radio9" value="0" checked="true"><label for="radio90">根本没有——0分</label><br><input type="radio" id="radio91" name="radio9" value="1" style=""><label for="radio91">有时候——1分</label><br><input type="radio" id="radio92" name="radio9" value="2"><label for="radio92">大多时候——2分</label><br><input type="radio" id="radio93" name="radio9" value="3"><label for="radio93">几乎所有时候——3分</label><br></group></span></p></td></tr><tr class="" style=""><td colspan="2">
<!--StartFragment--><p class="15" style="margin-top:1.9000pt;margin-left:25.3500pt;line-height:15.6500pt;
mso-line-height-rule:exactly;"><span style="font-size: 10.5pt;"><span style="letter-spacing: 0.25pt; position: relative; top: -5pt;">4）我能够安闲而轻松地坐着</span><o:p></o:p></span></p><p class="15" style="margin-left: 24.75pt;"><group type="radio" id="radio10" style=""><input type="radio" id="radio100" name="radio10" value="0" checked="true"><label for="radio100">肯定--0分</label><br><input type="radio" id="radio101" name="radio10" value="1"><label for="radio101">经常--1分</label><br><input type="radio" id="radio102" name="radio10" value="2"><label for="radio102">并不经常--2分</label><br><input type="radio" id="radio103" name="radio10" value="3"><label for="radio103">更本没有--3分</label><br></group></p><!--EndFragment-->
</td></tr><tr class="" style=""><td colspan="2" style="">
<!--StartFragment--><p class="15" style="margin-top:2.9500pt;margin-left:25.6000pt;"><span style="font-size: 10.5pt;"><span style="letter-spacing: 0.25pt;">5）我有点坐立不安，好像感到非要活动不可</span><o:p></o:p></span></p><p class="15" style="margin-top: 5.2pt; margin-left: 24.75pt; line-height: 15.75pt;"><group type="radio" id="radio11" style=""><input type="radio" id="radio11__0" name="radio11" value="0" checked="true"><label for="radio11__0">根本没有——0分</label><br><input type="radio" id="radio11__1" name="radio11" value="1"><label for="radio11__1">并不很少——1分</label><br><input type="radio" id="radio11__2" name="radio11" value="2"><label for="radio11__2">是不少——2分</label><br><input type="radio" id="radio11__3" name="radio11" value="3"><label for="radio11__3">确实非常多——3分</label><br></group></p><!--EndFragment-->
</td></tr><tr class=""><td colspan="2" style=""><span>
</span><!--StartFragment--><p class="15" style="margin-top:3.9500pt;margin-left:25.5000pt;"><span style="letter-spacing: 0.2pt; font-size: 9pt;">6）</span><span style="font-size: 10.5pt;"><span style="letter-spacing: 0.2pt;">我突然发现有恐慌感</span><o:p></o:p></span></p><p class="15" style="margin-top:5.2000pt;margin-left:24.7500pt;line-height:15.7500pt;
mso-line-height-rule:exactly;"><group type="radio" id="radio12" style=""><input type="radio" id="radio12__0" name="radio12" value="0" checked="true"><label for="radio12__0">根本没有——0分</label><br><input type="radio" id="radio12__1" name="radio12" value="1"><label for="radio12__1">并非经常——1分</label><br><input type="radio" id="radio12__2" name="radio12" value="2"><label for="radio12__2">非常肯定，十分严重——2分</label><br><input type="radio" id="radio12__3" name="radio12" value="3"><label for="radio12__3">确实很经常——3分</label><br></group></p><!--EndFragment--><span>
</span></td></tr><tr class="" style=""><td colspan="2" style=""><span>
</span><!--StartFragment--><p class="15" style="margin-top:2.9500pt;margin-left:25.6500pt;line-height:15.7500pt;
mso-line-height-rule:exactly;"><span style="font-size: 10.5pt;"><span style="letter-spacing: 0.25pt; position: relative; top: -5pt;">7）我感到有点害怕，好像某个内脏器官变化了</span><o:p></o:p></span></p><p class="15" style="margin-left: 24.75pt;"><group type="radio" id="radio13" style=""><input type="radio" id="radio13__0" name="radio13" value="0" checked="true"><label for="radio13__0">根本没有——0分</label><br><input type="radio" id="radio13__1" name="radio13" value="1"><label for="radio13__1">有时——1分</label><br><input type="radio" id="radio13__2" name="radio13" value="2"><label for="radio13__2">很经常——2分</label><br><input type="radio" id="radio13__3" name="radio13" value="3"><label for="radio13__3">非常经常——3分</label><br></group></p><!--EndFragment--><span>
</span></td></tr><tr style="height: 35px"><td class="" id="" title="" style="border-color: rgb(0, 0, 0); background-color: rgb(255, 255, 255); vertical-align: middle; text-align: center"><p class="15" style="text-align: center; margin-top: 0pt; margin-left: 0pt;"><span style="letter-spacing: 0.1pt; font-size: 10.5pt;"><font face="宋体" style=""></font>
<!--StartFragment-->焦虑得分</span></p></td><td class="" style="border-width: 1pt; border-color: rgb(0, 0, 0)"><field tabindex="0" id="total2" name="total2" type="Text" contenteditable="true" class="input" title="文本输入域" value="0" data-code="" data-expression="= radio7 + radio8 + radio9 + radio10 + radio11 + radio12 + radio13" multiline="false" validate="false" format="" style="display: inline-block; min-width: 100px; text-align: left;">0</field><span>&nbsp;</span></td></tr><tr class=""><td colspan="1"><span>
</span><!--StartFragment--><p class="15" style="margin-top:1.7500pt;margin-left:129.0500pt;"><span style="font-size: 10.5pt;"><span>结果</span><o:p></o:p></span></p><p class="15" style="margin-top:0.0500pt;margin-right:0.6500pt;margin-left:124.2000pt;
text-indent:-97.2500pt;"><span style="font-size: 10.5pt;"><span style="letter-spacing: 0.2pt;"><font face="宋体">（</font>0-7分为阴性;8-10为轻度;11-14分为</span><span style="letter-spacing: 0.15pt;"><font face="宋体">中度</font>;15-21分为</span>&nbsp;<span style="letter-spacing: -0.1pt;">重</span><span style="letter-spacing: -0.1pt;">度）</span></span></p><!--EndFragment--><span>
</span></td><td colspan="1" class=""><field tabindex="0" id="field_4" name="field_4" type="Text" contenteditable="true" class="input" title="文本输入域" value="1" data-code="" data-expression="=total1 + total2" multiline="false" validate="false" format="" style="display: inline-block; min-width: 100px; text-align: left;">1</field>&nbsp;<br></td></tr></tbody></table></div><p class="MsoNormal" style="margin-left:90.0500pt;"><span style="position:absolute;z-index:1;margin-left:75.5000px;
margin-top:112.3333px;width:680.0000px;height:0.0000px;"><br></span><span style="position:absolute;z-index:1;margin-left:75.5000px;
margin-top:112.3333px;width:680.0000px;height:0.0000px;"><br></span><span style="position:absolute;z-index:1;margin-left:75.5000px;
margin-top:112.3333px;width:680.0000px;height:0.0000px;"><br></span></p><br></div><div id="_footer" style="position: relative; min-height: 0.65cm; padding-left: 0.65cm; padding-right: 0.65cm; padding-bottom: 0.65cm; outline: none;" contenteditable="false" class=""></div>
</div>

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<div id="_page"
style="margin: 0px auto; background: rgb(255, 255, 255); width: 209.5mm; min-height: 148mm; transform: scale(1, 1); transform-origin: 50% 0px 0px;"
pagekind="A5" direct="landscape">
<div id="_header"
style="outline: none; min-height: 0.5cm; padding-left: 1cm; padding-right: 1cm; padding-top: 0.65cm; position: relative;"
contenteditable="false" class="">
<div style="text-align: center; line-height: 1.5;"><span
style="font-size: x-large; font-weight: 700;">成都中医药大学附属第一医院</span></div>
<div style="text-align: center; line-height: 1;"><span
style="font-weight: bold; font-size: large;">电子病历</span></div>
<div style="text-align: center;"><span
style="font-weight: bold; font-family: 楷体; line-height: 1; color: rgb(255, 255, 255); font-size: 5pt;">.</span>
</div>
</div>
<div id="_body" style="min-height: calc(472.441px); padding-left: 1cm; padding-right: 1cm;"
contenteditable="false" class="">
<div style="text-align: left;" domain="" code="" title="" contenteditable="false"><span
style="font-size: small; text-align: justify; font-weight: bold;" domain="" code="" title=""
contenteditable="false">姓名：</span>
<field tabindex="0" id="pat_name" type="Text" contenteditable="false" class="input" title="姓名"
name="pat_name" data-code="" data-expression="" multiline="false" validate="false" format=""
style="font-size: small; text-align: justify;" value=""></field><span
style="font-size: small; text-align: justify;">&nbsp; &nbsp;</span><span
style="font-size: small; text-align: justify; font-weight: bold;" domain="" code="" title=""
contenteditable="false">性别：</span>
<field tabindex="0" id="pat_sex" type="Text" contenteditable="false" class="input" title="性别" value="男"
name="pat_sex" data-code="" data-expression="" multiline="false" validate="false" format=""
style="font-size: small; text-align: justify;">男</field><span
style="font-size: small; text-align: justify;">&nbsp; &nbsp;</span><span
style="font-size: small; text-align: justify; font-weight: bold;" domain="" code="" title=""
contenteditable="false">年龄：</span>
<field tabindex="0" id="pat_age" type="Text" contenteditable="false" class="input" title="年龄"
name="pat_age" data-code="" data-expression="" multiline="false" validate="false" format=""
style="font-size: small; text-align: justify;" value=""></field><span
style="font-size: small; text-align: justify;">&nbsp; &nbsp;</span><span
style="font-size: small; text-align: justify; font-weight: bold;" domain="" code="" title=""
contenteditable="false">就诊科室：</span>
<field tabindex="0" id="visit_dept" type="Text" contenteditable="false" class="input" title="就诊科室"
name="visit_dept" data-code="" data-expression="" multiline="false" validate="false" format=""
style="font-size: small; text-align: justify;" value="风湿免疫科">风湿免疫科</field><span
style="font-size: small; text-align: justify; font-weight: bold;" domain="" code="" title=""
contenteditable="false">&nbsp; &nbsp;就诊号：</span>
<field tabindex="0" type="Text" contenteditable="false" class="input" title="就诊号" data-code=""
data-expression="" multiline="false" validate="false" format="" style="font-size: small;" domain=""
code="" required="false" inputmode="" id="pat_id" name="pat_id" value="MZ07882405098">
MZ07882405098</field><span style="font-size: small; text-align: justify;">&nbsp;</span>
</div>
<div style="text-align: justify; line-height: 2;"><span style="line-height: 2;"><span
style="font-weight: 700; line-height: 2;">
<hr style="font-size: small;"><span style="font-size: 9pt;">就诊时间：</span>
</span>
<field tabindex="0" id="visit_time" type="Text" class="input" title="就诊时间" name="visit_time"
data-code="" data-expression="" multiline="false" validate="false" format=""
style="font-size: 9pt;" value="2024-05-09 14:21:52">2024-05-09 14:21:52</field>
<field tabindex="0" type="Text" class="blank input" title="就诊时间" name="visit_time" data-code=""
data-expression="" multiline="false" validate="false" format=""
style="font-weight: 700; font-size: 9pt;">&nbsp;</field>
</span><span style="font-size: 9pt; line-height: 2;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
<group type="radio" id="firstcall" domain="" code="" style=""><input type="radio" id="firstcall__0"
name="firstcall" value="1" checked><label for="firstcall__0">初诊</label><input type="radio"
id="firstcall__1" name="firstcall" value="2"><label for="firstcall__1">复诊</label></group>
</span></div>
<div style="text-align: justify; line-height: 2;"><span style="font-size: 9pt; line-height: 2;"><span
style="font-weight: bold;">联系电话：</span>
<field tabindex="0" id="pat_phone" type="Text" class="input" title="联系电话" name="pat_phone"
data-code="" data-expression="" multiline="false" validate="false" format=""
contenteditable="true" style="" value=""></field><span style="" domain=""
code="" title=" "><span style="font-weight: bold;">&nbsp; 家庭住址：</span>
<field tabindex="0" id="pat_address" name="pat_address" type="Text" contenteditable="true"
class="blank input" title="地址" domain="" code="" multiline="true" required="false" format=""
inputmode="" data-expression="" value="">地址</field>
</span>
</span></div>
<div style="text-align: justify; line-height: 2;"><span style="font-size: 9pt; line-height: 2;"><span
style="font-weight: bold;">主诉：</span>
<field tabindex="0" id="pat_appeal" name="pat_appeal" type="Text" contenteditable="true"
class="input" title="主诉" domain="" code="" multiline="true" required="false" format=""
inputmode="" data-expression="" style="" value=""></field><span
style="font-weight: bold;">&nbsp;</span>
</span></div>
<div style="text-align: justify; line-height: 2;"><span style="font-size: 9pt; line-height: 2;"><span
style="" title="" domain="" code=""><span style="font-weight: bold;">现病史：</span>
<field tabindex="0" id="pat_now_history" name="pat_now_history" type="Text"
contenteditable="true" class="input" title="病史" domain="" code="" multiline="true"
required="false" format="" inputmode="" data-expression="" style=""
value=""></field><span
style="font-weight: bold;">&nbsp;</span>
</span></span></div>
<div style="text-align: justify; line-height: 2;"><span style="font-size: 9pt; line-height: 2;"><span
style="font-weight: bold;">既往史：</span>
<field tabindex="0" id="pat_past_history" name="pat_past_history" type="Text" contenteditable="true"
class="blank input" title="既往史" domain="" code="" multiline="true" required="false" format=""
inputmode="" data-expression="" style="">既往史</field><span
style="font-weight: bold;">&nbsp;</span>
</span></div>
<div style="text-align: justify; line-height: 2;" domain="" code="" title=" "><span
style="font-size: 9pt; line-height: 2;"><span style="font-weight: bold;">过敏史：</span>
<field tabindex="0" id="pat_allergy_history" name="pat_allergy_history" type="Text"
contenteditable="true" class="blank input" title="过敏史" domain="" code="" multiline="true"
required="false" format="" inputmode="" data-expression="" style="">过敏史</field><span
style="font-weight: bold;">&nbsp;</span>
</span></div>
<div style="text-align: justify; line-height: 2;"><span style="font-size: 9pt; line-height: 2;"><span
style="font-weight: bold;">诊断：</span>
<field tabindex="0" id="diagnosis" name="diagnosis" type="Text" contenteditable="true" class="input"
title="诊断" domain="" code="" multiline="true" required="false" format="" inputmode=""
data-expression="" style="" value=""></field>
</span></div>
<div style="text-align: justify; line-height: 2;"><span style="font-size: 12px;"><span
style="font-weight: 700;">处方：</span>
<field tabindex="0" id="presc" name="presc" type="Text" contenteditable="false" class="input"
title="处方" domain="" code="" multiline="true" required="false" format="" inputmode=""
data-expression="" style="" value=""></field><span style="font-weight: 700;">&nbsp;</span>
</span></div>
<div style="text-align: justify; line-height: 2;"><span style="font-size: 9pt; line-height: 2;"><span
style="font-weight: bold;">建议：</span>
<field tabindex="0" id="advice" type="Text" contenteditable="true" class="input" title="建议" domain="" code=""
multiline="true" required="false" format="" inputmode="" data-expression="" style=""
value="在用药过程中有任何身体不适，请及时前往实体医院就诊">在用药过程中有任何身体不适，请及时前往实体医院就诊</field><span
style="font-weight: bold;">&nbsp;</span>
</span></div>
<div style="text-align: justify; line-height: 2;"><span style="font-size: 9pt; line-height: 2;"><span
style="font-weight: bold;"><br></span></span></div>
<div style="text-align: justify; line-height: 2;" domain="" code="" title="" contenteditable="false"><span
style="font-weight: bold; line-height: 2; font-size: 9pt;">医师签字：</span>
<field tabindex="0" id="doctor_name" type="Text" contenteditable="false" class="input" title="医师签字"
name="doctor_name" data-code="" data-expression="" multiline="false" validate="false" format=""
style="line-height: 2; font-size: 9pt;" domain="" code="" required="false" inputmode="" value="贾连荣">
张某某</field><span style="line-height: 2; font-size: 9pt;">&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;
&nbsp; <span style="font-weight: bold; line-height: 2;">手签：</span></span>
</div>
</div>
<div id="_footer"
style="outline: none; position: relative; min-height: 0.5cm; padding-left: 1cm; padding-right: 1cm; padding-bottom: 0.65cm;"
contenteditable="false" class="">
<div style="text-align: center;"><span style="font-size: small;">第<field page="pageNum" style="">#</field>
页,共<field page="pageTotal" style="">#</field>页</span></div>
</div>
</div>

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<div id="_page" style="margin: 0px auto; background: rgb(255, 255, 255); width: 210mm; min-height: 297mm; transform: scale(1, 1); transform-origin: 50% 0px 0px;" pagekind="A4" direct="portrait">
<div id="_header" style="outline: none; min-height: 0.99cm; padding-left: 1.5cm; padding-right: 1.5cm; padding-top: 0.99cm; position: relative;" contenteditable="false" class="">
<p style=" font-family: 宋体; font-size: 15.75pt; text-align: Center;">
<label style=" font-family: 宋体; font-size: 15.75pt; font-weight: bold; text-align: Center;">云南城投昆明妇女儿童医院</label>
</p><p style=" font-family: 宋体; font-size: 14.25pt; text-align: Center;">
<label style=" font-family: 宋体; font-size: 15.75pt; font-weight: bold;">麻醉知情同意书</label>
</p></div>
<div id="_body" style="outline:none;min-height: calc(297mm - 0.99cm - 0.48cm - 0.99cm - 1.5cm);padding-left:1.5cm;padding-right:1.5cm;" contenteditable="false" class="">
<p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">姓名:</label>
<field tabindex="0" id="姓名" name="姓名" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title="姓名">姓名</field>
<label style=" font-family: 仿宋; font-size: 14.25pt;"> 性别:</label>
<field tabindex="0" id="性别" name="性别" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title="性别">性别</field>
<label style=" font-family: 仿宋; font-size: 14.25pt;"> 年龄:</label>
<field tabindex="0" id="年龄" name="年龄" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title="年龄">年龄</field>
<label style=" font-family: 仿宋; font-size: 14.25pt;"> 门诊号:</label>
<field tabindex="0" id="病历号" name="病历号" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title="病历号" data-code="" validate="false" format="">病历号</field>&nbsp;<label style=" font-family: 仿宋; font-size: 14.25pt;">科室:</label>
<field tabindex="0" id="科室" name="科室" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title="{科室}">科室</field>&nbsp;<label style=" font-family: 仿宋; font-size: 14.25pt;"> 床号:</label>
<field tabindex="0" id="日期" name="日期" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title="床号">床号</field>
</p><p style=" font-family: 仿宋; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">诊断:</label>
<field tabindex="0" id="诊断" name="诊断" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title="诊断" data-code="" validate="false" format="">诊断</field>&nbsp;<label style=" font-family: 仿宋; font-size: 14.25pt;">执行检查手术: </label>
<field tabindex="0" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title="执行手术">执行手术</field>
<label style=" font-family: 仿宋; font-size: 14.25pt;"> 体重: </label>
<field tabindex="0" id="体重" name="体重" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title="体重" data-code="" validate="false" format="alpha">{体重}</field>
<label style=" font-family: 仿宋; font-size: 14.25pt;">k</label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">任何麻醉均有风险性，在根据患者病情，切实做好麻醉前准备并按操作规范认真做好麻醉工 作及范防范措施情况下，仍有可能发生以下难以避免的麻醉意外及并发症：</label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">1、根据麻醉需要及操作规范，遵照《中华人民共和国药典》要求使用各种麻醉药物和输液用液体 后，由于患者体制原因，出现输液反应，过敏、高敏反应，致热源反应等，甚至导致过敏性休 克、呼吸心跳停止； </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">2、麻醉期间可能发生恶心、呕吐、返流误吸、喉水肿、喉痉挛，导致气道梗阻，窒息；</label>
<label style=" font-family: 宋体; font-size: 14.25pt;"> </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">3、呼吸抑制甚至短暂呼吸暂停；血压下降；心率减慢；严重者可能发生心跳呼吸骤停； </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">4、因麻醉诱发原有隐患匿性疾病发作，如哮喘、癫痫、心脑血管意外等； </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">5、因抢救需要气管插管，可能损伤患者口唇、牙齿、引起反流误吸、气道痉挛、窒息； </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">6、其他难以预料的并发症及意外。 </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">麻醉后注意事项 </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">1、麻醉结束后2小时内不要饮水、进食； </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">2、接受麻醉后当天，不能驾驶机动车，骑自行车及电动车，不能经行精细操作工作和高空作业； </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">3、麻醉结束后，请在医院观察休息一段时间，待麻醉医生认可后，方能离开； </label>
</p><p style=" font-family: 宋体; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">我们将以良好的医德医术为患者实行麻醉，力争将麻醉风险降低到最低程度，保障患者安全。上 述情况以对患者及家属说明，并对患者方提出的问题作了详细的解答，经慎重考虑，患者及家属 对麻醉可能出现的风险表示充分的理解，同意要求实行麻醉，签字为证：</label>
</p><p style="undefined" id="" title="患者签名">
<label style=" font-family: 仿宋; font-size: 14.25pt;">患者本人签字</label><img type="sign" alt="双击手写签名" style="width: 120px; height: 40px;" draggable="false" id="patient-sign" name="patient-sign" title=""><span style="font-size: 14.25pt;"> 签字时间_____年___月___日___ 时____分 </span></p><p style=" font-family: 仿宋; font-size: 14.25pt;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">患者家属签字</label><img type="sign" alt="双击手写签名" style="width: 120px; height: 40px;" draggable="false" id="patient-family-sign" name="patient-family-sign" title="家属签名"><span style="font-size: 14.25pt;">与患者关系_____</span></p><p style=" font-family: 仿宋; font-size: 14.25pt; text-align: Center;"><br></p><p style=" font-family: 宋体; font-size: 12pt; text-align: Right;">
<label style=" font-family: 仿宋; font-size: 14.25pt;">麻醉医师签名： <img readonly style="width: 120px; height: 80px;" type="sign" alt="医生签名" id="doctor-sign" name="doctor-sign" title="医生签名">      </label>
</p><p style=" font-family: 宋体; font-size: 12pt; text-align: Right;">
<field tabindex="0" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title=""></field>
<label style=" font-family: 仿宋; font-size: 14.25pt;">年</label>
<field tabindex="0" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title=""></field>
<label style=" font-family: 仿宋; font-size: 14.25pt;">月</label>
<field tabindex="0" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title=""></field>
<label style=" font-family: 仿宋; font-size: 14.25pt;">日</label>
<field tabindex="0" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title=""></field>
<label style=" font-family: 仿宋; font-size: 14.25pt;">时</label>
<field tabindex="0" class="blank" style=" font-family: 仿宋; font-size: 14.25pt;" contenteditable="true" type="Text" value="" title=""></field>
<label style=" font-family: 仿宋; font-size: 14.25pt;">分</label>
<label style=" font-family: 仿宋; font-size: 14.25pt; text-align: Right;"> </label>
</p></div>
<div id="_footer" style="outline:none; position:relative;min-height:1.5cm;padding-left:1.5cm;padding-right:1.5cm;padding-bottom:0.48cm;" contenteditable="false" class="">
<p style=""><label style=" font-family: 宋体; font-size: 10.5pt; color: #323232;">                                                             </label>&nbsp;</p></div>
</div>

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