大便潜血检查
大便潜血检查体检表格
一、基本信息
姓名：_____________________性别：____________________
年龄：_____________________体检日期：_________________
联系电话：___________________联系地址：_________________
二、病史信息
1.既往病史：
____________________________________________________________________
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2.家族病史：
____________________________________________________________________
____________________________________________________________________
三、生活习惯
1.饮食习惯：
____________________________________________________________________
____________________________________________________________________
2.排便习惯：
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____________________________________________________________________
3.是否长期服用某些药物：
____________________________________________________________________
____________________________________________________________________
四、大便潜血检查
1.检查目的：
____________________________________________________________________
____________________________________________________________________
2.检查方法：
____________________________________________________________________
____________________________________________________________________
3.检查前准备：
____________________________________________________________________
____________________________________________________________________
五、检查结果
1.大便潜血检查结果：
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____________________________________________________________________
2.结果解读与建议：
____________________________________________________________________
____________________________________________________________________
六、体检总结
1.对其他体检项目的建议：
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____________________________________________________________________
2.体检医生签字：____________________日期：___________________
七、注意事项
1.大便潜血检查对于早期肠胃道疾病的检测具有重