双向转诊信息调查表

组织机构代码           45124876-9

机构名称（签章）：      北川羌族自治县人民医院                                     

1.1 患者姓名                                                                      

1.2 性别代码（1男，2女） □

1.3 年龄                       身份证号码：                                   

1.4 档案/病案编号                                                             

1.5 家庭住址：              市                县                              

1.6 联系电话                                                                  

1.7 转诊类别（1门诊，2住院） □

1.8 转出时间：        年      月      日

1.9 转诊方式（1转入，2转回） □

2.0 转入/转回单位：                                                           

2.1 转入科室：                                                                      

2.2 接诊医生：                                                                   

2.3 转诊医生：                                                                

2.4 转诊医生联系电话：                                                           

2.5 初步印象（诊断）：                                                            

2.6 主要现病史（转出原因）：                                                   

2.7 主要既往史：                                                              

2.8 治疗经过、下一步治疗方案及康复建议：                                      

2.9 备注：                                                                       

单位负责人：赵  华       统计负责人：赖绍林            科主任签字：    

填  表  人：             联系电话：                    手      机：

报出日期：    年    月    日