|
Response to last treatment
|
|
|
Chief Complaint
|
Comments
|
|
Secondary Chief Complaint
|
Comments
|
|
New Symptoms
|
|
|
Energy Level
• • •
|
Comments
|
|
Sleep
• • •
|
Comments
|
|
Temp/Sweat
• • •
|
Comments
|
|
Appetite
• • •
|
Comments
|
|
Thirst
• • •
|
Comments
|
|
Digestion
• • •
|
Comments
|
|
BM
• • •
|
Comments
|
|
Urination
• • •
|
Comments
|
|
HEENT
|
Comments
|
|
LMP
|
Comments
|
|
Emotional
• • •
|
Comments
|
|
Exercise
• • •
|
Comments
|
|
Pain
|
|
|
Other:
|
|
|
|
|
|
Physical Exam of Chief Complaint
|
Blood Pressure
• • •
|
|
Blood Pressure Results
|
|
|
|
|
|
|
|
|
Pulse
|
|
|
Tongue
|
|
|
|
|
|
Hara
|
Shen
|
|
Organ Muscle Test
• • •
|
|
|
|
|
|
Etiology
|
|
|
Present Diagnosis
|
|
|
Treatment Principle
|
Differential
|
|
|
|
|
Points
/
|
Method
• • •
|
|
Details
|
|
|
Points
/
|
Method
• • •
|
|
Details
|
|
|
Points
/
|
Method
• • •
|
|
Details
|
|
|
Points
/
|
Method
• • •
|
|
Details
|
|
|
|
|
|
Total Number of Needles
|
Needles retained/minutes:
|
|
Adjuvant Therapies
• • •
|
Details
|
|
|
|
|
Herbal Formula
|
Type
• • •
|
|
|
|
|
Recommendations
• • •
|
Details:
|
|
Treatment Plan
|
|
|
Thoughts for next visit
|
|
