Name 姓名
Sex 性别
Age 年齡
Occupation 職業
Date of birth 出生日期
Marriage (Marital status) 婚姻
Race 民族
Place of birth (Birth place) 籍貫
Identification No.(code of ID card No.) 身份證号碼
Post code 郵政編碼
Person to notify (Correspondent) and phone No. 聯系人及電話
Source (Complainer;offerer;supplier;provider) of history 病史陳術者
Reliability of history 病史可靠程試
Medical security (Type of payment) 醫療費用
Type of admission (Patient condition) 住院類别(入院時病情)
Medical record No. 病曆号
Clinic diagnosis 門診診斷
Date of admission (admission date) 入院日期
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