|
Surrounding Circumstances
|
Notes
|
|
Pain Scale
|
Notes
|
|
Timing
|
Notes
|
|
Frequency
|
Notes
|
|
Pain Quality
|
Notes
|
|
Dermatome
• • •
|
Notes
|
|
Myotome
• • •
|
Notes
|
|
|
|
|
Hara Diagnosis
|
|
|
Manaka Hara
• • •
|
Notes
|
|
Manaka Hara
• • •
|
Notes
|
|
Manaka Hara
• • •
|
Notes
|
|
Manaka Hara
• • •
|
Notes
|
|
Manaka Hara
• • •
|
Notes
|
|
Manaka Hara
• • •
|
Notes
|
|
|
|
|
Orthopedic tests
• • •
|
Notes
|
|
Orthopedic tests
• • •
|
Notes
|
|
Orthopedic tests
• • •
|
Notes
|
|
Orthopedic tests
• • •
|
Notes
|
|
|
|
|
Meridian Stretch Test
|
|
|
Lung, Large Intestine, Ren
• • •
|
Notes
|
|
Heart, Small Intestine, Du
• • •
|
Notes
|
|
Pericardium & Dai
• • •
|
Notes
|
|
San Jiao & Dai
• • •
|
Notes
|
|
Spleen, Stomach, Ren
• • •
|
Notes
|
|
Urinary Bladder & Du
• • •
|
Notes
|
|
Gallbladder & Dai
• • •
|
Notes
|
|
Liver & Dai
• • •
|
Notes
|
|
|
|
|
Blood Pressure
|
|
|
Systole
|
Diastole
|
|
Blood Pressure
/
|
Notes
|
|
|
|
|
Acupuncture Point
|
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
Point
|
Details
• • •
|
|
|
|
|
Total number of needles
|
Retention on Front/Back
/
|
|
|
|
|
Adjunctive Therapy
|
|
|
Adjunctive Therapy
|
Notes
|
|
Adjunctive Therapy
|
Notes
|
|
Adjunctive Therapy
|
Notes
|
|
Adjunctive Therapy
|
Notes
|
|
Adjunctive Therapy
|
Notes
|
|
|
|
|
Herbal Formula
|
Type
|
|
|
|
|
Diet & Lifestyle recommendations
|
Referals
|
|
Notes
|
|
