|
Chief Concern
|
Status
|
|
Intensity (0-10)
|
Intensity (word value)
|
|
Quality of Pain
• • •
|
Onset
|
|
|
Patient also states...
|
|
2nd Concern
|
Status
|
|
Intensity (0-10)
|
Intensity (word value)
|
|
Onset
|
Quality of Pain
• • •
|
|
Patient also states...
|
|
|
3rd Concern
|
Status
|
|
Intensity (0-10)
|
Intensity (word value)
|
|
Onset
|
Quality of Pain
• • •
|
|
Patient also states...
|
|
|
Add'l objective...
|
|
|
Sleep
• • •
|
Energy
• • •
|
|
Appetite
• • •
|
Digestion
• • •
|
|
Emotions
• • •
|
Stress
• • •
|
|
Last Menstrual Period
|
Pregnant
|
|
Menses
• • •
|
Pregnancy notes
|
|
Range of Motion
• • •
|
Range of Motion
|
|
Left Pulse
• • •
|
Right Pulse
• • •
|
|
Tongue
• • •
|
Channel Diagnosis
• • •
|
|
TCM DX
• • •
|
Weight Loss Protocol
• • •
|
|
Auricular Points
• • •
|
Extra points
• • •
|
|
LU (Hand Tai Yin)
• • •
|
LI (Hand Yang Ming)
• • •
|
|
SP (Foot Tai Yin)
• • •
|
ST (Foot Yang Ming)
• • •
|
|
HT (Hand Shao Yin)
• • •
|
SI (Hand Tai Yang)
• • •
|
|
KD (Foot Shao Yin)
• • •
|
UB (Foot Tai Yang)
• • •
|
|
PC (Hand Jue Yin)
• • •
|
SJ (Hand Shao Yang)
• • •
|
|
LV (Foot Jue Yin)
• • •
|
GB (Foot Shao Yang)
• • •
|
|
REN (Conception Vessel)
• • •
|
DU (Governing Vessel)
• • •
|
|
Hua Tou
• • •
|
Other points used:
|
|
|
Notes
|
|
Massage/Tuina
|
Gua Sha
|
|
Moxa
• • •
|
Cupping
• • •
|
|
Infrared Heat Lamp
|
IR Lamp location
|
|
Patent Rx
• • •
|
Custom Herbs
• • •
|
|
DFEN
|
|
|
Self-care exercises
• • •
|
Future Plans/Recommendations
|
|
Referrals:
• • •
|
Referrals
|
|
Requested to bring next appt
• • •
|
|
|
Treatment Plan
• • •
|
Treatment plan notes
|
