2024年6月4日发(作者：)

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Medical n XXXX (n Code: XXXX-X) Medical Payment

Method: □ nal Chinese Medicine n Medical Record

Health Card Number: n Number: Name XXX (for those under

1 year old) Age Months XXX Province (n。City) City County

Native Place Province (n。City) City XXX Status □ied

d d ed Current Address

Province (n。City) City County Phone Number Postal Code

Registered Address Province (n。City) City County Postal Code

Work Unit and Address Unit Phone Number Postal Code Contact

Person Name nship Address Phone Number Mode of n □XXX

Treatment Type □ Chinese Medicine (1.1 nal Chinese

Medicine 1.2 Ethnic Medicine) Chinese and Western

Medicine

XXX) Disease Code

Diagnosis at Outpatient (XXX) Disease Code

XXX: □ Chinese Medicine n Medicine

Used Use of Chinese XXX: □ Use of nal Chinese XXX:

□ Use of nal Chinese XXX: □ n of

Syndrome n Nursing: □

nal XXX Discharge

Main Disease

Main Symptom

Disease Code

n n

XXX

Main Diagnosis

Other Diagnosis

Disease Code

n n: 。al Indeterminate。n。

XXX

Pathological Diagnosis: Disease Code

XXX