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CONTRAINDICATION checked?
Contraindication list
• • •
Notes on Contraindication
subjective
pain location
pain level
ROM
Ortho, palp and other
Gait, Posture, Movement
ART Tx
Laterality - DO NOT LEAVE BLANK!!
Adhesions
Laterality
Adhesions
Laterality
Adhesions
Laterality
Adhesions
Laterality
Adhesions
long nerve
• • •
Plan- ART treatment highlights
Plan for future treatment
ART Tx Response
Tx notes
Ren Ying - Cun Kou Pulse Dx
Ren Ying vs Cun Kou Pulse Size
(L) Ren Ying vs Cun Kou Pulse Size
(R) Ren Ying vs Cun Kou Pulse Size
Cun Kou vs Ren Ying Pulse Size
(L) Cun Kou vs Ren Ying Pulse Size
(R) Cun Kou vs Ren Ying Pulse Size
(L) vs (R) Ren Ying Pulse Size
(R) vs (L) Ren Ying Pulse Size
(L) vs (R) Cun Kou Pulse Size
(R) vs (L) Cun Kou Pulse Size
Ren Ying- Cun Kou Pulse notes
Ren Ying- Cun Kou Pulse notes
Meridian Dx from Ren Ying Cun Kou Pulse
"Zao" - Ren Ying Cun Kou Pulse
Acup Meridian Dx
Acup Tx Plan (Do not leave blank!!)
Pulse Dx
Pulse diagram
Pulse overall
Pulse (R)
Pulse (L)
R - 3 pulse positions:
(R) Cun:
(R) Guan:
(R) Chi:
L - 3 pulse positions:
(L) Cun:
(L) Guan:
(L) Chi:
Pulse notes
Pulse notes
Dr Tan Acup
Scalp Acup
Scalp Acup notes
Scalp (center line & paraspinal)
Center line & Paraspinal:
Scalp (L)
(L):
Scalp (R)
(R):
Upper (R)
Upper (R) Acup notes
UR- Extra points
Extra points
UR - Yang Meridians
UR- LI
LI point(s)
UR- SJ
SJ point(s)
UR- SI
SI point(s)
UR - Yin Meridians
UR- LU
LU point(s)
UR- PC
PC point(s)
UR- HT
HT point(s)
Upper (L)
Upper (L) Acup notes
UL- Extra points
Extra points
UL Yang Meridians
UL- LI
LI point(s)
UL- SJ
SJ point(s)
UL- SI
SI point(s)
UL - Yin Meridians
UL- LU
LU point(s)
UL- PC
PC point(s)
UL- HT
HT point(s)
Lower (L)
Lower (L) Acup notes
LL- Extra points
Extra points
LL - Yang Meridians
LL- ST
ST point(s)
LL- GB
GB point(s)
LL- UB
UB point(s)
LL - Yin Meridians
LL- SP
SP point(s)
LL- LR
LR point(s)
LL- KI
KI point(s)
Lower (R)
Lower (R) Acup notes
Lr- Extra points
Extra points
Lr - Yang Meridians
Lr- ST
ST point(s)
Lr- GB
GB point(s)
Lr- UB
UB point(s)
Lr - Yin Meridians
Lr- SP
SP point(s)
Lr- LR
LR point(s)
Lr- KI
KI point(s)
Plan-Acup treatment UR
Plan-Acup treatment UL
Plan-Acup treatment LR
Plan-Acup treatment LL
Plan-Acup treatment Rt
Plan-Acup treatment Lt
Plan-Acup treatment Bilateral
Plan-Acup treatment Bilateral
Plan-Acup treatment
Plan-Acup treatment
Second round needle applications
Second round needle application notes
Needle insertion
Needle insertion notes
Needle insertion Rt
Needle insertion Lt
Needle insertion Bilateral
Needle insertion Bilateral
Needle insertion
Needle insertion notes
Needle removal
Needle removal notes
Needle removal Rt
Needle removal Lt
Needle removal
Needle removal notes
Acup Tx Response
Acup Tx notes
Myofascia Release
Plan for future treatment
Spinal Adjustments
• • •
Spinal adjustment comments
Other Treatment 1
Other Treatment 2
Overall Tx Response
Overall Tx notes
Exercises - if performed, DO NOT LEAVE BLANK!!
Pre-Set Exercises
• • •
Exercise notes
Stretching Exercises
• • •
Exercise notes
at home exercises
• • •
Treatment Notes
Total Exercise time

Travel Card - Acup (Rev 1) Medical Form

Chiropractor

Action Performance Care

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Published: Sept. 22, 2023, 1:42 a.m.
Doctor: Dr. History Physical
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