Case Study Report Outline
We are collecting case studies for students, teachers and practitioners to use to support their practice and teaching. Zoom mentoring groups are also available (schedule coming soon) or go to our Mentors page if you would like one on one mentoring. Thank you for your support!
Email
*
example@example.com
1. ATTESTATION STATEMENT
I (clinician) confirm each of the following: 1. the information provided here accurately reflects the course of care and outcomes for the case; 2. All identifying information has been removed 3. by supplying this information, I confirm that based on my office policies, or communication with the patient whose data is provided here, I have consent to supply this information without identifiers.
*
I agree
2. CLINICIAN INFORMATION
In what country do you practice ?
*
United States
Afghanistan
Akrotiri
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Ashmore and Cartier Islands
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Bassas da India
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Coral Sea Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Dhekelia
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Europa Island
Falkland Islands (Islas Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Gibraltar
Glorioso Islands
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Jan Mayen
Japan
Jersey
Jordan
Juan de Nova Island
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Namibia
Nauru
Navassa Island
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paracel Islands
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Spratly Islands
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tromelin Island
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands
Wake Island
Wallis and Futuna
West Bank
Western Sahara
Yemen
Zambia
Zimbabwe
What type of herbal training did you complete?
*
Degree program
Academically accredited certification program
Other certification program
Other
How many years have you been practicing Chinese herbal medicine?
*
0-1
2-5
6-10
11-20
20+
Do you hold any registration or licensure to practice to Chinese herbal medicine?
*
NCCAOM
state licensure
national registration
national licensure
Where did you receive your herbal medicine training
*
United States
Afghanistan
Akrotiri
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Ashmore and Cartier Islands
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Bassas da India
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Coral Sea Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Dhekelia
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Europa Island
Falkland Islands (Islas Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Gibraltar
Glorioso Islands
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Jan Mayen
Japan
Jersey
Jordan
Juan de Nova Island
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Namibia
Nauru
Navassa Island
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paracel Islands
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Spratly Islands
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tromelin Island
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands
Wake Island
Wallis and Futuna
West Bank
Western Sahara
Yemen
Zambia
Zimbabwe
Do you have specific mentors for Chinese herbology? Please list.
Do you identify with any of the following paradigms when practicing Chinese herbal medicine?
Shang Han Lun
Wen Bing
Zang Fu
modern Chinese herbal medicine (e.g. including use of herbs as antivirals)
Kampo
Approximately how many acute infectious disease patients have you treated this year?
*
0-1
2-5
6-10
11-20
20+
3. PATIENT DEMOGRAPHICS
Brief Patient Description
e.g. 39 y.o. female publicist, history of asthma (Must remain the same in each entry for this patient)
Treatment/s
*
1st treatment
2nd treatment
3rd treatment
4th treatment
5th treatment
6th treatment
7th treatment
8th treatment
9th treatment
10th or more treatment
Age
*
0-1
2-5
6-10
11-20
20-29
30-39
40-49
50-59
60-69
70-79
80-89
90-99
100+
Gender
*
Female
Male
Transgender MTF
Transgender FTM
Non-binary
Prefer not to answer
Other
Pregnant?
*
Yes
No
Unsure
N/A
Race
*
American Indian/Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Black or African American
White
Unknown or Not reported
Ethnicity
*
Hispanic or Latino
NOT Hispanic or Latino
Comorbidities
*
Hypertension (controlled)
Hypertension (uncontrolled)
Type 2 diabetes (controlled)
Type 2 diabetes (uncontrolled)
Coronary disease; Congestive heart failure
Other CVD
COPD (non-asthma)
COPD (asthma)
Auto-immune or other inflammatory condition
Cancer
None known
Medical History, current or past
*
History of lung problems, including pneumonia, asthma, COPD, or recent cold/flu, or other lung diseases
History of heart problems, such as high or low blood pressure, diagnosed heart disease, angina, heart surgery, arrhythmia, atrial fibrillation (“a fib”), plaque in your arteries, high cholesterol,
History of diabetes, whether Type 1 or type 2, metabolic syndrome
History of digestive problems such as diarrhea, constipation, IBS, or other digestive disease
None known
Pharmaceuticals
*
Prescription anti-virals, (choloriquine)
Prescription anti-viral (non-choloriquine)
Anti-hypertention (ACEI)
Anti-hypertention (non-ACEI)
Lipid-lowering medications
Other cardiovascular medications
Corticosteriods (oral)
Corticosteroids (topical)
NSAIDS; Acetaminophen
Antibiotics
Anti-asthma medications
Other immunosuppressant medications
Cancer treatment/chemotherapy
Cancer treatment/radiation
Cancer treatment/other
Other prescription medications
Unknown
None
Does the patient have...
Smoking history
Vaping history
Insufficient financial resources to cover basic necessities
Covid-19 Status (at time of treatment)
Tested positive
Tested negative
Suspected due to symptoms
Suspected due to exposure
Not known
not applicable/supportive care
4. THERAPEUTIC GOAL
Therapeutic goal
Health promotion/Prevention
Acute symptom management
Recovery/convalescence
5. PATIENT SYMPTOM DATA:
5A - POTENTIALY C19 RELATED
Patient chief concern
Fever, if any
Below 99 but feeling hot or elevated for this patient
99-100.4 (37-38)
100.5-102.2 (38-39)
above 102.2 (39)
No thermometer but feeling hot/feverish
Sweat, if any
Light
Profuse
Spontaneous (daytime)
Nighttime
Hands/feet and chest
Oily on forehead
One-sided
None
Fatigue
*
1
2
3
4
not at all
exhausted
1 is not at all, 4 is exhausted
Cough
*
Dry
Clear, thin phlegm
White phlegm
Yellow, thin phlegm
Yellow, thick phlegm
Blood-tinged phlegm
None known
Shortness of breath
*
1
2
3
4
not at all
severe
1 is not at all, 4 is severe
Chest tightness
*
1
2
3
4
not at all
severe
1 is not at all, 4 is severe
Is patient able to take a deep breath?
*
Yes
No
Not assessed
Unusual feeling in throat (weird, tight, sore, etc.)?
*
Yes
No
Not assessed
Eye discharge (more than usual)?
*
Yes
No
Not assessed
Diarrhea?
*
Yes
No
Not assessed
Abdominal pain?
*
Yes
No
Not assessed
Changes in how food tastes or smells?
*
Yes
No
Not assessed
Other, potentially Covid-19 related symptoms
5B - 10 QUESTIONS (as applicable)
Headache Location
Top of head
Sides of head
Occiput
Frontal
Headache Quality
Severe
Dull
Chronic
Distending/throbbing
Boring or stabbing
Worse with recent illness
Eye symptoms (other than discharge, above)
Pain
Swelling
Redness
Blurry vision/'floaters'
Dryness
Ear symptoms
Tinnitus
Hearing loss
Pain location
Pain quality
Constant
Irregular
Sharp
Dull
Better with pressure
Worse with fatigue
Urination, stool, digestion
Nocturia
Frequent daytime Urination
Urgency
Inhibited urination
Lack of urination
BM less than daily
Constipation
Diarrhea
Loose stools
Acid reflux
Bloating
Belching
Stomach pain
Thirst, appetite
Lack of appetite in AM
Distended abdomen
Excessive thirst
Sleep
Difficulty falling asleep
Wakefulness
Insufficient sleep more than occasionally
Wake not feeling refreshed
5C OBSERVATION
Tongue body
Black spots
Cracks
Deviated
Dusky
Enlarged
Flabby
Long
Pale
Peeled
Quivering
Red
Red sides
Red spots
Red tip
Rough texture
Scallops
Scarlet
Small
Sores on tongue
Stiff
Swollen
Tender texture
Thick tongue body
Thin tongue body
White spots
Tongue coat
Thick
Thin
Little coat
No coat
Geographic/patchy
White
Yellow
Gray
Black
Dry
Greasy
Moist / wet
No root
6. DIAGNOSIS DATA
Primary Theoretical Paradigm selected for this case
*
Shang Han Lun
Wen Bing
Zang Fu
Modern Chinese herbal medicine (e.g. including use of herbs as antivirals)
Kampo
None
Reasoning for theoretic paradigm selected
if applicable
Key Diagnostic points
*
7. DETAILS OF FORMULA
Base Formula
Bai Hu Tang
Ban Xia Hou Po Tang
Chi Ge Jie Ji Tang
Chai Hu Gui Zhi Tang
Da Yuan Yin
Er Chen Tang
Gan Lu Xiao du Yin
Ge Gen Tang
Gui Zhi Tang
Hou Po Xia Ling Tang
Huo Xiang Zheng Qi San
Ling Gui Zhu Gan Tang
Ma Huang Tang
Ma Xing Shi Gan Tang
Mai Men Dong Tang
Qing Fei pai du yin
San Ren Tang
Sang Ju Yin
Sha Shen Mai Dong Tang
She Ga Ma Huang Tang
Sheng Mai San
Wei Jing Tang
Wu Ling San
Xiao Chai Hu Tang
Xiao Xian Xiong Tang
Secondary Formula
Bai Hu Tang
Ban Xia Hou Po Tang
Chi Ge Jie Ji Tang
Chai Hu Gui Zhi Tang
Da Yuan Yin
Er Chen Tang
Gan Lu Xiao du Yin
Ge Gen Tang
Gui Zhi Tang
Hou Po Xia Ling Tang
Huo Xiang Zheng Qi San
Ling Gui Zhu Gan Tang
Ma Huang Tang
Ma Xing Shi Gan Tang
Mai Men Dong Tang
Qing Fei pai du yin
San Ren Tang
Sang Ju Yin
Sha Shen Mai Dong Tang
She Ga Ma Huang Tang
Sheng Mai San
Wei Jing Tang
Wu Ling San
Xiao Chai Hu Tang
Xiao Xian Xiong Tang
If no base formula used, individual formula written
Bai Dou Kou
Bai He , Lilii Bulbus
Bai Shao , Paeoniae Radix Alba
Bai Zhu , Atractylodis Macrocephalae Rhizoma
Ban Len Gen , Isatidis Root , Isatis root
Ban Xia , Pinelliae Rhizoma , Pinellia
Bo He , Menthae haplocalycis Herbs , Mentha, field mint
Chai Hu , Bupleuri Radix, Buplerum, hare's ear root
Chuan Bei Mu , Fritillariae Cirrhosae Bulbus , Sichuan fritillaria bulb
Chuan Xiong , Radix Ligustici Chuanxiong
Da Huang , Rhei Radix et Rhizoma , Rhubarb
Da Qing Ye, Isatidis Folium , Isatis leaf
Dan Dou Chi , Sojae Semen preparatum , Prepared soybean
Dan Shen , Radix Salviae Miltiorrhizae , Salvia root
Dan Zhu Ye
Dang Gui , Angelicae Sinensis Radix
Dang Shen , Codoopsis Radix
Fang Feng , Saposhnikoviae Radix , Ledebouriella root, Siler
Fu Ling , Poria , Poria / hoelen
Fu Zi , Aconiti Radix Lateralis Praeparata
Ge Gen , Puerariae Radix , Kudzu root, peuraria
Gua Lou , Trichonsanthis Fructus
Gui Zhi , Cinnamomi Ramulus , Cinnamon Twig Cassia Twig
Hou Po , Cortex Magnoliae Officinalis
Huang Bai , Phellodendri Cortex
Huang Lian , Coptidis Rhizome , Coptis / Goldthread rhizome
Huang Qi , Astragali Radix
Huang Qin , Scutellaria Radix , Skullcap root / scute
Huo Xiang , herba Pogostemi seu Agastaces
Jie Geng , Platycodonis Radix , Platycodon root / Balloonflower root
Jin Yin Hua , Lonicerae Flos , Honeysuckle
Jing Jie , Schizonepetae Herba,
kuan dong hua
Lian Qiao , Forsythiae Fructus , Forsythia fruit
Ma Huang , Ephedrae Herba , Ephedra
Mai Men Dong , Ophiopogonis Radix
Pi Pa Ye , Eriobotryae Folium
Qiang Huo , Notopterygii Rhizoma seu Radix
Qing Hao , Artemisiae Annuae Herba
Ren Shen , Ginseng Radix
Sang Ye , Mori Folium , White mulberry leaf
Sha Shen , Glehniae/Adeophoeae Radix
She Gan , Belamcandae Rhizoma , Belamcanda
Sheng Di Huang , Rehamnniae Radix , Dried Chinese foxglove root
Shi Gao , Gypsum fibrosum
Shi Hu , Dendrobii Herba
Tao Ren , Semen Persicae
Tian Hua Fen , Trichosanthis Radix , Trichosanthes root
Wu Wei Zi , Schisandrae Fructus
Wu Zhu Yu , Evodiae Fructus
Xi Yang Shen , Panacis Quinquefolii Radix
Xin Yi Hua , Magnoliae Flos , Magnolia flower
Xing Ren , Armeniacae Semen , Bitter Apricot Kernel
Yi Yi Ren , Coicis Semen , Coix seed / Job's tears
Ze Xie , Alismatis Rhizoma
Zhi Mu , Anemarrheanae Rhizoma
Zhi Shi , Fructus Immaturus Citri aurantii , Unripe bitter orange
Zhi Zi , Gardeniae Fructus , Gardenia fruit
Zhu Ling , Polyporus
Zhu Ru , Bambusae Caulis in Taenia
Zi Su Ye , Perillae Folium
Zi Wan , Asteris Radix
Substances added to base formula
Bai Dou Kou
Bai He , Lilii Bulbus
Bai Shao , Paeoniae Radix Alba
Bai Zhu , Atractylodis Macrocephalae Rhizoma
Ban Len Gen , Isatidis Root , Isatis root
Ban Xia , Pinelliae Rhizoma , Pinellia
Bo He , Menthae haplocalycis Herbs , Mentha, field mint
Chai Hu , Bupleuri Radix, Buplerum, hare's ear root
Chuan Bei Mu , Fritillariae Cirrhosae Bulbus , Sichuan fritillaria bulb
Chuan Xiong , Radix Ligustici Chuanxiong
Da Huang , Rhei Radix et Rhizoma , Rhubarb
Da Qing Ye, Isatidis Folium , Isatis leaf
Dan Dou Chi , Sojae Semen preparatum , Prepared soybean
Dan Shen , Radix Salviae Miltiorrhizae , Salvia root
Dan Zhu Ye
Dang Gui , Angelicae Sinensis Radix
Dang Shen , Codoopsis Radix
Fang Feng , Saposhnikoviae Radix , Ledebouriella root, Siler
Fu Ling , Poria , Poria / hoelen
Fu Zi , Aconiti Radix Lateralis Praeparata
Ge Gen , Puerariae Radix , Kudzu root , peuraria "
Gua Lou , Trichonsanthis Fructus
Gui Zhi , Cinnamomi Ramulus , Cinnamon Twig Cassia Twig
Hou Po , Cortex Magnoliae Officinalis
Huang Bai , Phellodendri Cortex
Huang Lian , Coptidis Rhizome , Coptis / Goldthread rhizome
Huang Qi , Astragali Radix
Huang Qin , Scutellaria Radix , Skullcap root / scute
Huo Xiang , herba Pogostemi seu Agastaces
Jie Geng , Platycodonis Radix , Platycodon root / Balloonflower root
Jin Yin Hua , Lonicerae Flos , Honeysuckle
Jing Jie , Schizonepetae Herba,
kuan dong hua
Lian Qiao , Forsythiae Fructus , Forsythia fruit
Ma Huang , Ephedrae Herba , Ephedra
Mai Men Dong , Ophiopogonis Radix
Pi Pa Ye , Eriobotryae Folium
Qiang Huo , Notopterygii Rhizoma seu Radix
Qing Hao , Artemisiae Annuae Herba
Ren Shen , Ginseng Radix,
Sang Ye , Mori Folium , White mulberry leaf
Sha Shen , Glehniae/Adeophoeae Radix
She Gan , Belamcandae Rhizoma , Belamcanda
Sheng Di Huang , Rehamnniae Radix , Dried Chinese foxglove root
Shi Gao , Gypsum fibrosum
Shi Hu , Dendrobii Herba
Tao Ren , Semen Persicae
Tian Hua Fen , Trichosanthis Radix , Trichosanthes root
Wu Wei Zi , Schisandrae Fructus
Wu Zhu Yu , Evodiae Fructus
Xi Yang Shen , Panacis Quinquefolii Radix
Xin Yi Hua , Magnoliae Flos , Magnolia flower
Xing Ren , Armeniacae Semen , Bitter Apricot Kernel
Yi Yi Ren , Coicis Semen , Coix seed / Job's tears
Ze Xie , Alismatis Rhizoma
Zhi Mu , Anemarrheanae Rhizoma
Zhi Shi , Fructus Immaturus Citri aurantii , Unripe bitter orange
Zhi Zi , Gardeniae Fructus , Gardenia fruit
Zhu Ling , Polyporus
Zhu Ru , Bambusae Caulis in Taenia
Zi Su Ye , Perillae Folium
Zi Wan , Asteris Radix
Substances subtracted from base formula
Bai Dou Kou
Bai He , Lilii Bulbus
Bai Shao , Paeoniae Radix Alba
Bai Zhu , Atractylodis Macrocephalae Rhizoma
Ban Len Gen , Isatidis Root , Isatis root
Ban Xia , Pinelliae Rhizoma , Pinellia
Bo He , Menthae haplocalycis Herbs , Mentha, field mint
Chai Hu , Bupleuri Radix, Buplerum, hare's ear root
Chuan Bei Mu , Fritillariae Cirrhosae Bulbus , Sichuan fritillaria bulb
Chuan Xiong , Radix Ligustici Chuanxiong
Da Huang , Rhei Radix et Rhizoma , Rhubarb
Da Qing Ye, Isatidis Folium , Isatis leaf
Dan Dou Chi , Sojae Semen preparatum , Prepared soybean
Dan Shen , Radix Salviae Miltiorrhizae , Salvia root
Dan Zhu Ye
Dang Gui , Angelicae Sinensis Radix
Dang Shen , Codoopsis Radix
Fang Feng , Saposhnikoviae Radix , Ledebouriella root, Siler
Fu Ling , Poria , Poria / hoelen
Fu Zi , Aconiti Radix Lateralis Praeparata
Ge Gen , Puerariae Radix , Kudzu root , peuraria "
Gua Lou , Trichonsanthis Fructus
Gui Zhi , Cinnamomi Ramulus , Cinnamon Twig Cassia Twig
Hou Po , Cortex Magnoliae Officinalis
Huang Bai , Phellodendri Cortex
Huang Lian , Coptidis Rhizome , Coptis / Goldthread rhizome
Huang Qi , Astragali Radix
Huang Qin , Scutellaria Radix , Skullcap root / scute
Huo Xiang , herba Pogostemi seu Agastaces
Jie Geng , Platycodonis Radix , Platycodon root / Balloonflower root
Jin Yin Hua , Lonicerae Flos , Honeysuckle
Jing Jie , Schizonepetae Herba,
kuan dong hua
Lian Qiao , Forsythiae Fructus , Forsythia fruit
Ma Huang , Ephedrae Herba , Ephedra
Mai Men Dong , Ophiopogonis Radix
Pi Pa Ye , Eriobotryae Folium
Qiang Huo , Notopterygii Rhizoma seu Radix
Qing Hao , Artemisiae Annuae Herba
Ren Shen , Ginseng Radix,
Sang Ye , Mori Folium , White mulberry leaf
Sha Shen , Glehniae/Adeophoeae Radix
She Gan , Belamcandae Rhizoma , Belamcanda
Sheng Di Huang , Rehamnniae Radix , Dried Chinese foxglove root
Shi Gao , Gypsum fibrosum
Shi Hu , Dendrobii Herba
Tao Ren , Semen Persicae
Tian Hua Fen , Trichosanthis Radix , Trichosanthes root
Wu Wei Zi , Schisandrae Fructus
Wu Zhu Yu , Evodiae Fructus
Xi Yang Shen , Panacis Quinquefolii Radix
Xin Yi Hua , Magnoliae Flos , Magnolia flower
Xing Ren , Armeniacae Semen , Bitter Apricot Kernel
Yi Yi Ren , Coicis Semen , Coix seed / Job's tears
Ze Xie , Alismatis Rhizoma
Zhi Mu , Anemarrheanae Rhizoma
Zhi Shi , Fructus Immaturus Citri aurantii , Unripe bitter orange
Zhi Zi , Gardeniae Fructus , Gardenia fruit
Zhu Ling , Polyporus
Zhu Ru , Bambusae Caulis in Taenia
Zi Su Ye , Perillae Folium
Zi Wan , Asteris Radix
Notes on relative dosage of substances if applicable
Method of administration
Raw
Vacuum pack
Granule
Tincture
Number of grams/day of granules
1-10
11-20
21-30
31-40
41-50
51-60
61-80
More than 80
Number of packets/day (raw)
1
2
3
4
5
6
7
1 is , 7 is
Other notes on formula
8. TREATMENT REGIMEN
At what point in disease process was this treatment administered
*
Prevention
Early Symptoms
Mid Symptoms
Late Symptoms
Recovery
Days formula taken
*
1
2
3
4
5
6
7
1 is , 7 is
Response at 24 hours
Positive/Improved
Negative
Not sure
N/A
Response at 48 hours
Positive/Improved
Negative
Not sure
N/A
Response at 72 hours
Positive/Improved
Negative
Not sure
N/A
Notes on treatment response
*
Please provide any additional details about the patient/client's trajectory of care, including your clinical impressions of how useful your care may have been.
9. OTHER COMPONENTS OF TREATMENT
Setting and context of treatment
*
Office
Telemedicine
Other
Other treatment received from you
*
Acupuncture
Acupressure
Moxibustion
Cupping
Exercises
Qi Gong
Tui Na
Tai Ji
Lifestyle Advice
None
Treatment received from other providers
*
Acupuncture
Acupressure
Moxibustion
Cupping
Exercises
Qi Gong
Tui Na
Tai Ji
Lifestyle Advice
None known
10. OUTCOMES
Common/possible side effects of herbal therapy
*
GI upset
Headache
Sweating
None
Patient chief concern
Fever, if any
Below 99 but feeling hot or elevated for this patient
99-100.4 (37-38)
100.5-102.2 (38-39)
above 102.2 (39)
Sweat, if any
Light
Profuse
Spontaneous (daytime)
Nighttime
Hands/feet and chest
Oily on forehead
None
Fatigue
1
2
3
4
Not at all
Severe
1 is Not at all, 4 is Severe
Cough
Dry
Clear, thin phlegm
White phlegm
Yellow, thin phlegm
Yellow, thick phlegm
Blood-tinged phlegm
None
Shortness of breath
1
2
3
4
Not at all
Severe
1 is Not at all, 4 is Severe
Chest tightness
1
2
3
4
Not at all
Severe
1 is Not at all, 4 is Severe
Are you able to take a deep breath?
Yes
No
Not assessed
Unusual feeling in throat (weird, tight, sore, etc.)?
Yes
No
Not assessed
Eye discharge (more than usual)?
Yes
No
Not assessed
Diarrhea?
Yes
No
Not assessed
Abdominal pain?
Yes
No
Not assessed
Changes in how food tastes or smells?
Yes
No
Not assessed
Other, potentially Covid-19 related symptoms
Overall case outcome:
*
Not infected with COVID
Full recovery remained outpatient
Partial recovery remained outpatient, hospitalization ICU
hospitalization other
Death
Patient remains under care/outcomes to be added later
GENERAL COMMENTS
General Comments
*
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