|
Chief Complaint
|
2nd cc:
|
|
Additional cc information
|
|
|
Chills/Fever
|
Abnormal Sweating
|
|
Appetite
• • •
|
Food Preferences
• • •
|
|
Thirst
• • •
|
Drink Preferences
• • •
|
|
Bowel Movements
|
Urination
|
|
EENT
|
Chest/Respiratory
|
|
Mouth/Throat
|
Cardiovascular
|
|
GI/Abdomen
|
Urogenital
|
|
Energy (1-10)
• • •
|
Head/Migraine
|
|
Emotional Health
|
Skin
|
|
Stress
• • •
|
Exercise
|
|
Sleep
|
|
|
|
|
|
Age of Menarche
|
Menses
|
|
Interval Since Last Period
|
Date of Last Period
|
|
PMS Symptoms
|
Duration of Period
|
|
Color of Blood
• • •
|
Amount of Blood
• • •
|
|
Clots
|
Clot Description
|
|
|
STD/Yeast infection/UTIs
|
|
Current Contraception Method
|
Contraception History
|
|
Pregnant
|
EDC/Due Date
|
|
Date of Menopause
|
Bleeding/Spotting Since Menopause
|
|
Libido
|
Breasts
|
|
|
|
|
Location of Pain
|
Neurological
|
|
Date of Onset
|
Frequency
• • •
|
|
Quality of Pain
• • •
|
Severity (1-10)
• • •
|
|
Aggravating Factors
|
Relieving Factors
|
|
Duration of Pain
|
Medications
|
|
Biomedical Diagnosis
|
Tests/Lab Results
|
|
Other Tx Modalities
|
|
|
|
|
|
Pulses
|
Tongue
|
|
TCM Diagnosis
|
Treatment Principle
|
|
Points
|
E-Stim Points
|
|
1st 15min Acupuncture no E-Stim
|
1st 15min Acupuncture with E-Stim
|
|
2nd 15min Acupuncture no E-Stim
|
2nd 15min Acupuncture with E-Stim
|
|
3rd 15min Acupuncture no E-Stim
|
3rd 15min Acupuncture with E-Stim
|
|
Cupping
|
Cupping Areas
|
|
Moxibustion
|
Moxibustion Points
|
|
Gua Sha
|
Gua Sha Areas
|
|
Tui Na
|
Tui Na Areas
|
|
Herbs/Formulas
|
Referrals
|
|
Recommendations
|
|
