|
Chief Concern
|
Symptom Progress from Last Visit
|
|
New/Additional Symptoms
|
Notes
|
|
Sleep
• • •
|
Sleep Notes/Dreams
|
|
Energy
• • •
|
Libido
|
|
Appetite
• • •
|
Digestion
• • •
|
|
Bowel Movements
• • •
|
Urination
• • •
|
|
Thirst
• • •
|
Sweating
• • •
|
|
Emotionally
• • •
|
Stress
• • •
|
|
Notes
|
Observations
|
|
Last Menstrual Period
|
Pregnant
|
|
Menses
• • •
|
Pregnancy notes
|
|
Pain Location
• • •
|
Quality of Pain
• • •
|
|
Pain Level
• • •
|
Pain (Extra Notes)
|
|
Range of Motion
• • •
|
Range of Motion
|
|
Left Pulse
• • •
|
Right Pulse
• • •
|
|
Left Pulse Notes
|
Right Pulse Notes
|
|
Tongue
• • •
|
New Field
|
|
5 Element: Color
• • •
|
5 Element: Sound
• • •
|
|
5 Element: Odor
• • •
|
5 Element: Emotion
• • •
|
|
5 Element: CF-Causative Factor
• • •
|
TCM DX
• • •
|
|
Channel Diagnosis
• • •
|
Weight Loss Protocol
• • •
|
|
Auricular Points
• • •
|
Induce Labor
• • •
|
|
My Favorite Combos
• • •
|
Combo and Extra points
• • •
|
|
LU (Hand Tai Yin)
• • •
|
LI (Hand Yang Ming)
• • •
|
|
SP (Foot Tai Yin)
• • •
|
ST (Foot Yang Ming)
• • •
|
|
HT (Hand Shao Yin)
• • •
|
SI (Hand Tai Yang)
• • •
|
|
KD (Foot Shao Yin)
• • •
|
UB (Foot Tai Yang)
• • •
|
|
PC (Hand Jue Yin)
• • •
|
SJ (Hand Shao Yang)
• • •
|
|
LV (Foot Jue Yin)
• • •
|
GB (Foot Shao Yang)
• • •
|
|
REN (Conception Vessel)
• • •
|
DU (Governing Vessel)
• • •
|
|
Left points
|
Right Points
|
|
Other points used:
|
Assessment Notes
|
|
Infrared Heat Lamp
|
Moxa
• • •
|
|
Massage/Tuina
|
Cupping
• • •
|
|
Gua Sha
|
Electro-Stimulation
|
|
Herbal Prescription
|
Treatment Notes
|
|
Recommended:
• • •
|
Future Plans/Reccomendations
|
|
Referrals:
• • •
|
Referrals
|
|
Treatment Plan
• • •
|
Treatment plan notes
|
|
CPT Codes
• • •
|
Requested to bring next appt
• • •
|
|
Billing
• • •
|
Copay
|
|
Pain ICD-9
• • •
|
Women's Health ICD-9
• • •
|
|
GI/Digestive ICD-9
• • •
|
Cardio/Emotions/Energy/Sleep ICD
• • •
|
|
Urinary ICD-9
• • •
|
Respiratory ICD-9
• • •
|
