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Response to Last Treatment:
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Notes:
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Chief Complaint:
|
Notes:
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Onset:
|
Notes:
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Location:
|
Notes:
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Duration:
|
Overall Notes:
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Characteristics:
|
Notes:
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Aggravates:
|
Notes:
|
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Alleviates:
|
Notes:
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Related:
|
Notes:
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Treatments:
|
Notes:
|
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Severity:
|
Notes:
|
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Energy:
|
|
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Sleep:
|
|
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Temperature:
|
|
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Sweat:
|
|
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Appetite:
|
|
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Thirst:
|
|
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Digestion:
|
|
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Urination:
|
|
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Bowel Movements:
|
|
|
HEENT:
|
|
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Pain:
|
|
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Menses:
|
|
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Other:
|
|
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Tongue Body Color:
• • •
|
|
|
Tongue Body Shape:
• • •
|
|
|
Tongue Coat:
• • •
|
|
|
Tongue Picture:
|
|
|
Overall Pulse Quality:
• • •
|
|
|
Right Cun:
• • •
|
|
|
Right Guan:
• • •
|
|
|
Right Chi:
• • •
|
|
|
Left Cun:
• • •
|
|
|
Left Guan:
• • •
|
|
|
Left Chi:
• • •
|
|
|
TCM Diagnosis:
|
|
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Treatment Principle:
|
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Treatment Plan:
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