|
Other Related Symptoms
|
|
|
Facial Focus Areas
|
Previous Facial Tx(s)
|
|
|
|
|
Chills/Fever
|
Abnormal Sweating
|
|
Appetite
|
Food Preferences
• • •
|
|
Thirst
|
Drink Preferences
• • •
|
|
Digestion
|
Bowel Movements
|
|
Urination
|
EENT
|
|
Sleep
|
Stress
|
|
Exercise
|
Energy
|
|
Emotional Health
|
Libido
|
|
|
|
|
Health History
|
|
|
Head/Neck
|
Eyes/Ears
|
|
Mouth/Throat
|
Skin
|
|
Chest/Respiratory
|
Heart
|
|
GI/Abdomen
|
Urogenital
|
|
Breasts
|
Neurological
|
|
Other
|
|
|
|
|
|
Menarche
|
|
|
Age of Menarche
|
Duration of Period
|
|
Date of Last Period
|
Interval Since Last
|
|
Color of Flow
|
Amount of Flow
|
|
Clots
|
PMS Symptoms
|
|
Current Contraception Method
|
Contraception History
|
|
Date of Menopause
|
Bleeding Since Menopause
|
|
Pregnant
|
EDC/Due Date
|
|
Pertinent Pregnancy History
|
|
|
|
|
|
Musculoskeletal
|
|
|
Location of Pain
|
Date of Onset
|
|
Quality of Pain
• • •
|
Pattern of Pain
• • •
|
|
Duration of Pain
|
Severity (1-10)
• • •
|
|
Aggravating Factors
|
Relieving Factors
|
|
Other Tx Modalities
|
Medications
|
|
|
|
|
Pulse (Right)
|
Pulse (Left)
|
|
Tongue
|
Shen
|
|
|
|
|
TCM Diagnosis
|
Treatment Principle
|
|
Biomedical Diagnosis/ICD9
|
Course of Treatment
|
|
|
|
|
Facial Points
|
Facial Herbs
|
|
|
|
|
Points
|
No Acupuncture Given
|
|
E-Stim
|
Moxibustion
|
|
Myofascial Work
|
Tui Na
|
|
Infrared Therapy
|
Gua Sha
|
|
|
|
|
Herbs/Formulas
|
No Herbs Given
|
|
|
|
|
Recommendations
|
Referrals
|
