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Chief Concern
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Other Symptoms
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Sleep
• • •
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Energy
• • •
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Appetite
• • •
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Digestion
• • •
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Bowel Movements
• • •
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Thirst
• • •
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Urination
• • •
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Sweating
• • •
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Stress
• • •
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Last Menstrual Period
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Chills/Fever
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Menses
• • •
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Pain Location
• • •
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Quality of Pain
• • •
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Pain Level
• • •
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Pain (Extra Notes)
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Blood Pressure
/
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Pulse BPM
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Right Pulse
• • •
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Left Pulse
• • •
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Tongue
• • •
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TCM DX
• • •
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Channel Diagnosis
• • •
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Auricular Points
• • •
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Bilateral Points
• • •
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Points Used on Left
• • •
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Points used on Right
• • •
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Other points used on Left
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Other Points Used on Right
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Extra points
• • •
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Weight Loss Protocol
• • •
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Cupping
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Infrared Heat Lamp
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Herbal Prescription
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Notes
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Referrals:
• • •
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Recommended:
• • •
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Referrals
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Future Plans/Reccomendations
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Billing:
• • •
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