|
Chief Complaint
|
Treatments tried before
|
|
What is diagnosis by MD?
|
How long affected by condition
|
|
Current prescription meds
|
Vitamins & herbal supplements
|
|
Pain or Severity (1-10)
|
Sleep
|
|
How often you exercise?
|
Digestion
|
|
ENT
|
Headaches
|
|
Menses
|
Surgeries/Hospitalizations
|
|
Pulse
• • •
|
Tongue
• • •
|
|
Pulse Notes
|
Tongue Notes
|
