Progress Note
Date
-
Month
-
Day
Year
Intern
Patient Name
First Name
Last Name
Age
Gender
Subjective:
(please choose and write down details for items below)
Follow up Treatment
Yes
No
How do you feel since last treatment
Same
Better
Worse
Discomfort/Pain Assessment
Please Select
1
2
3
4
5
6
7
8
9
10
Items - Details:
Chief Complaint
List the main symptoms + duration
Onset
How to start, any inducement
Treatment History
Western Medicine Diagnosis
Features of Present Symptoms
Any accompanied symptoms? Anything/condition could make it worse/better?
Pain
How long time, dull, distending, stabbing, getting worse/better by, etc.
Cold/Heat
Fever, chill, usually feel cold/warm, etc.
Sweat
Yes/No, a lot/some/little, day/night, area, etc.
Sputum/Mucus/Nasal Discharge
Little/some/a lot, color, thin/thick/sticky, etc.
Head/Body
Headache, agitation, stiffness, fatigue, heaviness, shortness of breath, no desire to talk, etc.
Life Style
Alcohol, smoke, work time, etc.
Diet
Appetite, hungry easily, eat fast/slow, greasy, spicy, cold, hot, etc
Drink/Thirst
A lot, a little, cold, warm, etc.
Back
Next
Bowel Movement
Times per day, a lot/little, difficult/easy, loose/diarrhea, etc.
Urination
Frequency, clear/yellow/dark, pain, retention, blood, etc.
Sleep
Hour, dream disturbing, wake up during night, etc.
Emotion
Stress level, anxiety, sadness, etc.
Vomit/Nausea
Right after eating, couple hours after eating, undigested food, fluid, nausea, etc.
Menstruation
Cycle days, heavy/scanty, early, delayed, dark/light/purple, thin/thick, clots, pain, amenorrhea, menarche, etc.
Leukorrhea
Heavy/scanty,white/yellow/red/dark, smelly, etc.
Gestation
Pregnancy, delivery, miscarriage, etc.
Lab Test/Examination
Any western medicine examination
Other
Back
Next
Objective: Gait, ROM, complexion, eyes, nails, palpation,etc
Biomedical Findings:
Weight:
Height:
Temp:
Pulse:
BP:
RP:
Allergies:
Current Medication:
Tongue:
Pulse:
Overall Quality, Rate, Depth & Strength
Right
Left
Assessment:
Chief Complaint Diagnosis:
Additional TCM Pattern Differentiation:
Plan:
Treatment Principle:
Prognosis:
# of Tx per week:
Course of Tx:
Recommended # of Tx/re-evaluation:
Acupuncture Rx:
Moxa Rx:
E-Stim Rx:
Tui-Na:
Ear Rx: Seeds/Needle:
Bleeding Rx:
Cupping Rx/Gua Sha Rx:
Post Current Treatment Assessment:
Submit
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