|
Chief Complaint
|
Secondary Complaint
|
|
CC Severity
• • •
|
CC level of pain
|
|
CC Frequency
|
|
|
Secondary Complaint Severity
• • •
|
Secondary Complaint level of pain
|
|
Secondary Complaint Frequency
|
|
|
History of Present Illness
|
Response to last tx
|
|
Post tx response
|
|
|
Sleep
|
Digestion
|
|
Pain
|
Emotional
|
|
Temperature/Sweat
|
Stool/Urine
|
|
Energy Level
|
Appetite/Thirst
|
|
Menses LMP
|
HEENT
|
|
Other
|
|
|
Cun (left/right)
/
|
Guan (left/right)
/
|
|
Chi (left/right)
/
|
|
|
Tongue Body
|
Tongue Coat
|
|
Tongue Illustration
|
|
|
Indicate Areas of Concern:
|
Physical Exam
|
|
Diagnosis
• • •
|
Elaborate on Diagnosis
|
|
Treatment Principle(s)
|
Medications
|
|
Changes in Medications
|
|
|
Total # of Needles
|
Time retained (in minutes)
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Adjunction Treatments
|
Herbal Formula(s)
|
|
|
|
|
Education
|
|
|
Prognosis
|
Prognosis Duration
|
