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Chief Concern
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Other Symptoms
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|
Sleep
• • •
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Sleep Notes/Dreams
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Energy
• • •
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Libido
|
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Appetite
• • •
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Digestion
• • •
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Bowel Movements
• • •
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Urination
• • •
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Thirst
• • •
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Sweating
• • •
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Emotionally
• • •
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Stress
• • •
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Last Menstrual Period
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Pregnant
|
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Menses
• • •
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Pregnancy notes
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Pain Location
• • •
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Quality of Pain
• • •
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Pain Level
• • •
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Pain (Extra Notes)
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Range of Motion
• • •
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Range of Motion
|
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Left Pulse
• • •
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Right Pulse
• • •
|
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Tongue
• • •
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Channel Diagnosis
• • •
|
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TCM DX
• • •
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Weight Loss Protocol
• • •
|
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Auricular Points
• • •
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Extra points
• • •
|
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LU (Hand Tai Yin)
• • •
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LI (Hand Yang Ming)
• • •
|
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SP (Foot Tai Yin)
• • •
|
ST (Foot Yang Ming)
• • •
|
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HT (Hand Shao Yin)
• • •
|
SI (Hand Tai Yang)
• • •
|
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KD (Foot Shao Yin)
• • •
|
UB (Foot Tai Yang)
• • •
|
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PC (Hand Jue Yin)
• • •
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SJ (Hand Shao Yang)
• • •
|
|
LV (Foot Jue Yin)
• • •
|
GB (Foot Shao Yang)
• • •
|
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REN (Conception Vessel)
• • •
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DU (Governing Vessel)
• • •
|
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Other points used:
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Notes
|
|
Massage/Tuina
|
Gua Sha
|
|
Moxa
• • •
|
Cupping
• • •
|
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Infrared Heat Lamp
|
Herbal Prescription
|
|
Recommended:
• • •
|
Future Plans/Reccomendations
|
|
Referrals:
• • •
|
Referrals
|
|
Requested to bring next appt
• • •
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Billing:
• • •
|
|
Treatment Plan
• • •
|
Treatment plan notes
|
|
Pain ICD-9
• • •
|
Women's Health ICD-9
• • •
|
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GI/Digestive ICD-9
• • •
|
Cardio/Emotions/Energy/Sleep ICD
• • •
|
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Urinary ICD-9
• • •
|
Respiratory ICD-9
• • •
|
