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Treatment Plan (Initial Visit)
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DIAGNOSIS
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1.
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2.
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3.
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TREATMENT PRINCIPLE
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1.
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2.
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3.
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Total # of recommended treatments
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How many treatments per week?
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How many weeks?
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Date of Next Evaluation
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Declined Treatment Methods
• • •
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Comments
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TREATMENT PRESCRIBED
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Acupuncture
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Points/Notes
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# of needles used
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Bleeding
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Points/Notes
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Cupping
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Method
• • •
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Location/Notes
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Ear Seeds
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Notes
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Ear Diagram
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Electrical Stimulation
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Settings/Frequency
• • •
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Points/Notes
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Gua Sha
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Notes
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Full Body Diagram
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Kinesiology Tape
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Reason
• • •
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Full Body Diagram
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Notes
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Moxibustion
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Method
• • •
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Notes/Location
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Moxibustion (2)
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Method
• • •
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Notes/Location
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Herbal Prescription (1)
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Formula
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Type
• • •
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Granules
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Capsules/Pills
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How many times per day?
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Special Instructions
• • •
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Notes:
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Herbal Prescription (2)
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Formula
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Type
• • •
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Granules
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Capsules/Pills
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How many times per day?
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Special Instructions
• • •
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Notes:
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Herbal Prescription (3)
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Formula
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Type
• • •
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Granules
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Capsules/Pills
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How many times per day?
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Special Instructions
• • •
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Notes:
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