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Chief Complaint
• • •
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Comments
|
|
|
|
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CC level of pain
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CC Onset / Timing
|
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CC Frequency
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Date
|
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CC Quality
• • •
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CC Severity
• • •
|
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CC Modifying Factors
• • •
|
CC Duration
|
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CC Improv. since last visit
|
|
|
|
|
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Secondary Complaint
• • •
|
Comment
|
|
SC level of pain
|
date
|
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SC Frequency
|
SC Severity
• • •
|
|
SC Improv. since last visit
|
SC Quality
• • •
|
|
|
|
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Energy
• • •
|
Bowels
• • •
|
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Sleep
• • •
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Digestion
• • •
|
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Appetite
• • •
|
Mood
• • •
|
|
Temperature
• • •
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Thirst
• • •
|
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Dryness
• • •
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Chest
• • •
|
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Urination
• • •
|
Stress level
|
|
Male Reproductive
|
Female Reproductive
|
|
General WNL
|
General Abnormal
• • •
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Skin WNL
|
Skin Abnormal
• • •
|
|
Blood Pressure
/
|
Pulse Rate
|
|
Left Pulse
• • •
|
Right Pulse
• • •
|
|
Tongue Body
• • •
|
Tongue Coating
• • •
|
|
Tongue Illustration
|
Indicate Areas of Concern:
|
|
Physical Exam
• • •
|
Positive Physical Exams Findings
• • •
|
|
Eastern Diagnosis (TCM)
• • •
|
Elaborate on Diagnosis
|
|
Western diagnosis
• • •
|
Elaborate on Diagnosis
|
|
Time retained (in minutes)
|
|
|
Unit 1:
|
Unit 1
• • •
|
|
Unit 2:
|
Unit 2
• • •
|
|
Unit 3:
|
UNIT 3
• • •
|
|
Unit 4:
|
|
|
Adjunction Treatments
|
Additional Information
|
|
E-Stim:
|
Additional Information
|
|
Cupping:
|
Additional Information
|
|
Tui Na:
|
Additional Information
|
|
Therapeutic Exercise:
|
Additional Information
|
|
Gua Sha:
|
Additional Information
|
|
Heat:
|
Additional Information
|
|
Herbal Formula(s)
|
Dietary Suggestions
|
|
PLAN FOR PATIENT
|
Preferances and to Avoid
|
