既往史、个人史及家族史：

治疗经过（包括治疗、手术及抢救经过）：                                 

死亡情形：                                                            

                            体 格 检 查                              

一般情况：         T           P           R          BP            

肺：                                                                 

心：                                                                 

消化系统：                                                           

泌尿生殖系统：                                                        

神经系统：                                                            

四肢及其他：                                                          

                        实 验 室 器 械 检 查                          

入院时白细胞总数：       红细胞总数：        血小板：      其他：     

入院时白细胞分类：中性    % 淋巴    % 单核：  % 嗜酸性   % 其他：  

死亡前白细胞总数：       红细胞总数：        血小板：      其他：     

死亡前白细胞分类：中性    % 淋巴    % 单核：  % 嗜酸性   % 其他：  

尿；尿糖        蛋白        胆原        管型        细胞              

粪：虫卵        阿米巴      隐血        其他                         

痰、胃液、脑脊液：                                                   

微生物、血清学等;：                                               

X线检查：                                                           

其他检查：                                                                                        

委托医师嘱请解剖医师注意问题：                                             

死亡或代理人同意解剖签字：                                       

住院医师或主治医师委托解剖签字：