|
Chief Complaint
|
Sxs
|
|
Stress Capacity
|
Intensity (1-10)
|
|
Medication Levels
|
Frequency
|
|
Rebound Capacity
|
Affected ADL
|
|
Chills/Fever/Temp
|
Abnormal Sweating
|
|
Appetite
|
Thirst
|
|
Bowel Movements
|
Urination
|
|
Eyes/Ears/Nose/Throat
|
Energy
|
|
Sleep
|
Libido
|
|
Emotional Health
|
Other
|
|
|
|
|
Pain: Loc'n, Quality, Aggravating / Relieving
|
Date of Onset
|
|
Other Tx Modalities
|
Severity (1-10)
• • •
|
|
Tests/Lab Results
|
Medications
|
|
|
|
|
Menses
|
Pregnant (yes/no)
|
|
|
|
|
Pulse
|
Tongue
|
|
Physical Exam
|
|
|
|
|
|
TCM Diagnosis
|
Treatment Principle
|
|
Biomedical Diagnosis
|
ICD10
|
|
|
|
|
Points
|
Point Combos
|
|
E-Stim Points
|
Reinsertion (# of times)
|
|
Moxibustion Points
|
Cupping Areas
|
|
Infrared Areas
|
Massage / Acupressure Areas
|
|
Seated Evaluation Time (Minutes)
|
Total Treatment Time (minutes)
|
|
|
|
|
Herbs/Formulas/Dosage
|
Herbal Type
|
|
|
|
|
Recommendations / Education
|
Therapeutic Exercises
|
|
To Consider
|
Key Sxs
|
|
Referrals
|
|
