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Chief complaint
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Second Complaint
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Basic Notes
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10 Asking Song
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1. Fever & Chills
• • •
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2. Sweats
• • •
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3. Bowel Movement
• • •
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4. Urination
• • •
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5. Appetite & Thirst
• • •
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6. Sleep
• • •
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7. Ears and Eyes
• • •
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8. Leukorrhea
• • •
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Pain
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Complaint #1
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Pain severity on Complaint #1
• • •
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Complaint #2
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Pain severity on Complaint #2
• • •
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New Complaint
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Pain severity on New Complaint
• • •
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Nature
• • •
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Timing
• • •
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Pressure
• • •
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Temperature
• • •
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Food & Drink
• • •
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Bowel Movement
• • •
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Movement & Rest
• • •
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Pulse
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Left Pulse
• • •
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Right Pulse
• • •
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Tongue
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Tongue Body Color
• • •
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Details
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Tongue Body Shape
• • •
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Details
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Tongue Coating
• • •
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Details
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Dx
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Tx
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Acupuncture
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Points
/
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Details
• • •
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Points
/
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Details
• • •
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Points
/
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Details
• • •
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Points
/
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Details
• • •
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Points
/
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Details
• • •
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Auricular Points
/
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Details
• • •
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Auricular Points
/
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Needles retained/minutes:
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Total Number of Needles:
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Color/ Frequency/ Duration
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Laser Therapy
• • •
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Product/ cc/ Location
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Injection Therapy
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Recommendations
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Herbal Formula
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Supplements
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Notes
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