|
Patient Name
|
|
|
Chief complaint
|
Second Complaint
|
|
history of CC
|
|
|
Chi Assessment
|
|
|
1. Fever & Chills
• • •
|
2. Sweats
• • •
|
|
3. Bowel Movement
• • •
|
4. Urination
• • •
|
|
5. Appetite & Thirst
• • •
|
6. Sleep
• • •
|
|
7. Ears and Eyes
• • •
|
8. Energy
• • •
|
|
Hot or Cold
• • •
|
Headaches
|
|
LMP
|
Menses
• • •
|
|
Pain
|
|
|
Complaint #1
|
Pain severity on Complaint #1
• • •
|
|
Complaint #2
|
Pain severity on Complaint #2
• • •
|
|
New Complaint
|
Pain severity on New Complaint
• • •
|
|
Nature
• • •
|
Timing
• • •
|
|
Pressure
• • •
|
Temperature
• • •
|
|
Food & Drink
• • •
|
Bowel Movement
• • •
|
|
Movement & Rest
• • •
|
|
|
Pulse & Tongue
|
|
|
Left Pulse
• • •
|
Right Pulse
• • •
|
|
pulse details
|
pulse details
|
|
Tongue Body Color
• • •
|
Details
|
|
Tongue Body Shape
• • •
|
Details
|
|
Tongue Coating
• • •
|
details
|
|
Dx
|
Details
|
|
PLAN
|
|
|
Tx
|
Treatment plan details
|
|
Auricular
/
|
Auricular
• • •
|
|
Points
/
|
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
Details
• • •
|
|
Points
/
|
|
|
Points
/
|
|
|
points
/
|
|
|
Points
/
|
|
|
Points
/
|
|
|
Total Number of Needles:
|
Needles retained/minutes:
|
|
Needling notes
|
|
|
|
|
|
Herbal Formula
|
Supplements
|
|
Recommendations
|
|
