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Other Complaints
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Female Patient
|
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Last Period Date / Where at in Cycle
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Cycle Length
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Cramps (Pain Lvl) or Clots (Size)
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PMS Sx's
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What makes better? What has been tried?
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Blood Color / Consistency
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Bleeding Length / Pattern / Amt (tampon #?)
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Vaginal / Nipple Discharge
|
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Libido / Sexual Performance
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Other Gyn. Complaints / Conditions
|
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Pregnant
|
Pregnancy Notes
|
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Physical Pain+Location
|
ROM / Better or Worse
|
|
Pain Level
|
|
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Quality of Pain
• • •
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Stress
• • •
|
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Sleep
• • •
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Sleep Notes/Dreams
|
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Energy
• • •
|
Bowel Movements
• • •
|
|
Appetite
• • •
|
Digestion Notes
|
|
Thirst
• • •
|
Urination
• • •
|
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Sweating
• • •
|
Emotions
• • •
|
|
Emotion Notes
|
Misc Notes
|
|
Tongue
|
Pulse
|
|
TCM Dx / Western Dx
|
Treatment Principle
|
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Front and Back Points
|
Side Points
|
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Additional Points
|
Infrared Heat
|
|
Cupping / Moxa
|
Herbal Prescription
|
|
Dosage
|
Future Plans/Recommendations
|
|
Referrals
|
Requested to bring next appt
• • •
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