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HPI
|
Additional Symptoms
|
|
Energy
• • •
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Mood
• • •
|
|
Sleep
• • •
|
Temperature
• • •
|
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Appetite
• • •
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Sweating
• • •
|
|
Digestion
• • •
|
Thirst
• • •
|
|
Bowel Movements
• • •
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Urination
• • •
|
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Stress
• • •
|
Libido
• • •
|
|
Activity
• • •
|
Last Menstrual Period
|
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Menses
• • •
|
Notes on Menses Hx
|
|
Pain Level
• • •
|
|
|
Quality of Pain
• • •
|
Pain (Extra Notes)
|
|
Left Pulse Palpation
• • •
|
Right Pulse Palpation
• • •
|
|
TCM Tongue Examination
• • •
|
Pulse BPM
|
|
Physical Exam Findings
|
Blood Pressure
/
|
|
|
|
|
TCM DX
• • •
|
Assessment Notes
|
|
|
|
|
|
Plan Notes
|
|
Herbal Prescription
|
Future Plans/Reccomendations
|
|
Referrals:
• • •
|
Weight Loss Protocol
• • •
|
|
Referrals
|
Recommended:
• • •
|
|
|
Post-Tx Notes
|
|
Billing:
• • •
|
|
|
|
|
|
New Exam- 20 mins (99202)
|
Infrared (97026)
|
|
New Exam- 30 mins (99203)
|
Manual Therapy (97140)
|
|
Re-exam 10 mins (99212)
|
Manual Therapy (97140)
|
|
Re-exam 15 mins (99313)
|
Neuro Re-ed (97112)
|
|
Ther-ex (97110)
|
Neuromuscular Re-ed (97112)
|
|
ACU- Manual (97810)
|
ACU w/ E-stim (97813)
|
|
ACU- Manual reinsertion (97811)
|
ACU reinsertion w/ E-stim (97814)
|
