|
Chief Complaint
|
Other Related Symptoms
|
|
Intensity (1-10)
|
Frequency (how often)
|
|
Stress Capacity
|
Rebound Capacity
|
|
Medication Levels
|
|
|
|
|
|
Chills/Fever
|
Abnormal Sweating
|
|
Appetite
|
Food Preference
|
|
Thirst
|
Drink Preference
|
|
Bowel Movements
|
Urination
|
|
Eyes/Ears
|
Nose/Throat
|
|
Sleep
|
Stress
|
|
Exercise
|
Energy
|
|
Emotional Health
|
Libido
|
|
|
|
|
Head/Neck
|
Eyes/Ears
|
|
Mouth/Throat
|
Skin
|
|
Chest/Respiratory
|
Heart
|
|
GI/Abdomen
|
Urogenital
|
|
Breasts
|
Neurological
|
|
|
|
|
Menses (yes/no)
|
Age of Menses
|
|
PMS Symptoms
|
Date of Last Period
|
|
Interval Since Last
|
Duration of Period
|
|
Color Of Blood
|
Amount Of Blood
|
|
Clots (yes/no)
|
Clot Description
|
|
Current Contraception Method
|
Contraception History
|
|
Date of Menopause
|
Bleed'g/Spott'g Since Menopause?
|
|
Pregnant (yes/no)
|
EDC/Due Date
|
|
|
|
|
Location of Pain
|
Date of Onset
|
|
Quality of Pain
• • •
|
Frequency
• • •
|
|
Duration of Pain
|
Severity (1-10)
• • •
|
|
Aggravating Factors
|
Relieving Factors
|
|
Other Tx Modalities
|
Medications
|
|
Tests/Lab Results
|
|
|
|
|
|
Pulse
|
Tongue Body
|
|
Physical Exam
|
Tongue Fur
|
|
|
|
|
TCM Diagnosis
|
Treatment Principle
|
|
Biomedical Diagnosis
|
ICD9
|
|
|
|
|
Points
|
Point Combos
|
|
E-Stim Points
|
Cupping Areas
|
|
Moxibustion Points
|
Tui Na Areas
|
|
Infrared Areas
|
|
|
|
|
|
Herbs/Formulas
|
Herbal Type
|
|
Dosage
|
|
|
|
|
|
Recommendations
|
Referrals
|
|
To Consider
|
|
