|
Name
|
Weight (lbs)
|
|
Height
|
Onset of cycle
|
|
# of children / days of cycle
|
Qualities of cycle
|
|
|
|
|
Level of overall health (1-10)
|
Current prescription meds
|
|
Vitamins & herbal supplements
|
How often you exercise?
|
|
Here for what health issue?
|
Treatments tried before
|
|
What is diagnosis by MD?
|
How long affected by condition
|
|
Urinary
|
Bowel
|
|
Digestion
|
Emotional State
|
|
|
|
|
Pulse L
|
Pulse R
|
|
Pain Ranges
/
|
Tongue
|
|
|
Headaches with location
|
|
|
|
|
Subjective
|
Objective
|
|
Assessment - TCM Diagnosis
|
Plan - Treatment
|
