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Services Prior Today & Treatment Outcome
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Any Treatment Performed?
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Visits Rendered
/
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Total Visits
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Response to Care
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Current Main Compliant & Health History
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Mechanism of Injury/Onset
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Is this Work or Auto Related?
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Pain Areas and Level of Pain
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How Often Are Symptoms Present?
• • •
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Patient's Current Health Condition
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Can Patient Perform Daily Activities?
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Is Patient Currently Under Care of a Physician?
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If "Yes", Please Indicate for What Condition
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Any Ongoing Care (ex: meds, therapy, etc)
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General Health History: PAST
• • •
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General Health History: PRESENT
• • •
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Hospitalizations/Surgical Procedures
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Pregnancy (How Many Weeks)
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Medications (Indicate)
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Other
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Family History
• • •
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Other
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Vitals
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Height
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Weight
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Blood Pressure
/
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Pulse Rate
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Temperature
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Physical Exam (ROM, Observation, Palpation)
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General Findings
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Date of Clinical Findings
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Tongue Signs
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Pulse Signs
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Activities of Daily Living
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Comments and/or Additional Information
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Lab/Radiographic Exam Findings
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Date of Findings
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Condition Treated/Western Diagnosis
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Eastern Diagnosis
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Eight Priniciples
• • •
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Zang/Fu Dysfunction
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Qi Dysfunction
• • •
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Blood Dysfunction
• • •
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Five Elements
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Other
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Treatment / Services Submitting for Review
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Dates of Service
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Total # Office Visits/Acupuncture
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Established Patient
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Exam Date
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Treatment Objectives
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Therapies That May Be Utilized
• • •
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Home Care
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