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18
Questions
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1
Patient ID number
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2
Caregiver ID number
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3
Date
-
Date
שנה
חודש
יום
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4
Treatment No
*
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5
What is the main reason for coming to treatment (symptoms)
What is the main reason for coming to treatment ?
Duration (months)
Less than 1
1
2
3
4
5
6
7
8
9
10
11
12
more than 12
Duration (months)
Duration (months)
Less than 1
1
2
3
4
5
6
7
8
9
10
11
12
more than 12
Duration (months)
Rate of Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Frequency
Rate of Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Frequency (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Rate of Pain
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Pain
Rate of Pain
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Pain (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Rate of Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Intensity
Rate of Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Intensity (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Impaired ability to perform an action
1
2
3
4
5
6
7
8
9
10
not applicable
Impaired ability to perform an action
Impaired ability to perform an action
1
2
3
4
5
6
7
8
9
10
not applicable
Impaired ability to perform an action (1 the lowest to 10 the highest. If not applicable, select "not applicable")
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6
Other reason for coming to treatment (symptoms)
Yes
No
Yes
No
Are there other reasons?
What is the main reason for coming to treatment ?
Duration (months)
Less than 1
1
2
3
4
5
6
7
8
9
10
11
12
more than 12
Duration (months)
Duration (months)
Less than 1
1
2
3
4
5
6
7
8
9
10
11
12
more than 12
Duration (months)
Rate of Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Frequency
Rate of Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Frequency (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Rate of Pain
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Pain
Rate of Pain
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Pain (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Rate of Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Intensity
Rate of Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Rate of Intensity (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Impaired ability to perform an action
1
2
3
4
5
6
7
8
9
10
not applicable
Impaired ability to perform an action
Impaired ability to perform an action
1
2
3
4
5
6
7
8
9
10
not applicable
Impaired ability to perform an action (1 the lowest to 10 the highest. If not applicable, select "not applicable")
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7
Rate the following parameters
(1 the lowest to 10 the highest. If not applicable, select "not applicable")
Yes
No
Yes
No
Are the following questions relevant to your symptoms?
Range of motion
1
2
3
4
5
6
7
8
9
10
not applicable
Range of motion
Range of motion
1
2
3
4
5
6
7
8
9
10
not applicable
Range of motion (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Movement stiffness
1
2
3
4
5
6
7
8
9
10
not applicable
Movement stiffness
Movement stiffness
1
2
3
4
5
6
7
8
9
10
not applicable
Movement stiffness (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Degree of swelling
1
2
3
4
5
6
7
8
9
10
not applicable
Degree of swelling
Degree of swelling
1
2
3
4
5
6
7
8
9
10
not applicable
Degree of swelling (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Natural posture
1
2
3
4
5
6
7
8
9
10
11
12
Natural posture
Natural posture
1
2
3
4
5
6
7
8
9
10
11
12
Natural posture (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Muscle strength
1
2
3
4
5
6
7
8
9
10
not applicable
Muscle strength
Muscle strength
1
2
3
4
5
6
7
8
9
10
not applicable
Muscle strength (1 the lowest to 10 the highest. If not applicable, select "not applicable")
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8
Is there a western medical diagnosis?
Is there a western medical diagnosis?
Yes
No
Is there a western medical diagnosis?
Is there a western medical diagnosis?
Yes
No
Is there a western medical diagnosis?
Please Select
1B40.0 - - - - Rheumatic arthritis, acute or subacute
1F00 - - Herpes simplex infections
1F00.01 - - - - Herpes simplex labialis
1F00.2 - - - Herpes simplex infection of central nervous system
3A71 - - Anaemia due to chronic disease
4A43.2 - - - Sjögren syndrome
4A44 - - Vasculitis
4A80.Z - - - Allergic or hypersensitivity disorders involving the respiratory tract, unspecified
5A00 - - - Hypothyroidism
5A11 - - - Type 2 diabetes mellitus
5A80.2 - - - - Polycystic ovary
5B80.0 - - - - - Overweight
5B81 - - - - Obesity
5C80.0 - - - - Hypercholesterolaemia
6A05 - - Attention deficit hyperactivity disorder
6A71 - - - Recurrent depressive disorder
6A80.0 - - - Prominent anxiety symptoms in mood episodes
6B41 - - Complex post traumatic stress disorder
6B60.2 - - - Dissociative neurological symptom disorder, with vertigo or dizziness
6B60.84 - - - - Dissociative neurological symptom disorder, with facial spasm
6B60.85 - - - - Dissociative neurological symptom disorder, with Parkinsonism
7A00 - - Chronic insomnia
7A80 - - Restless legs syndrome
8A00.0 - - - Parkinson disease
8A05 - - Tic disorders
8A40 - - Multiple sclerosis
8A60 - - Epilepsy due to structural or metabolic conditions or diseases
8A80 - - Migraine
8A80.0 - - - Migraine without aura
8A80.1 - - - Migraine with aura
8A81 - - Tension-type headache
8B11 - - - Cerebral ischaemic stroke
8B82.0 - - - - Trigeminal neuralgia
8B88.0 - - - - Bell palsy
8B93 - - - Radiculopathy
8B93.6 - - - - Radiculopathy due to intervertebral disc disorders
8C00 - - - Idiopathic progressive neuropathy
8C03.0 - - - - Diabetic polyneuropathy
8C10.0 - - - - Carpal tunnel syndrome
8C10.1 - - - - Lesion of ulnar nerve
8C10.2 - - - - Lesion of radial nerve
8C11.0 - - - - Lesion of sciatic nerve
8C11.00 - - - - - Sciatic nerve piriformis syndrome
8C12.0 - - - - Intercostal neuropathy
8C70 - - - Muscular dystrophy
8E43.0 - - - Neuropathic pain
8E43.00 - - - - Phantom limb syndrome
9A11 - - - Disorders of lacrimal drainage system
9A60 - - - Conjunctivitis
9C61 - - Glaucoma
AB00 - - - Acute otitis media
AB01 - - - Chronic otitis media
AB31.0 - - - Meniere disease
AB31.2 - - - Benign positional paroxysmal vertigo
BA00 - - Essential hypertension
BA04 - - Secondary hypertension
BD42 - - - Raynaud phenomenon
BD74.1 - - - Lower limb varicose veins
CA01 - - Acute sinusitis
CA08.0 - - - Allergic rhinitis
CA09.0 - - - Chronic rhinitis
CA20.1 - - - Chronic bronchitis
CA22 - - Chronic obstructive pulmonary disease
CA23 - - Asthma
DA0E.8 - - - Temporomandibular joint disorders
DA22 - - Gastro-oesophageal reflux disease
DB60 - - - Haemorrhoids
DD70 - - Crohn disease
DD71 - - Ulcerative colitis
DD91.0 - - - Irritable bowel syndrome
DD91.1 - - - Functional constipation
DD91.2 - - - Functional diarrhoea
DD91.3 - - - Functional bloating
EA80 - - - Atopic eczema
EA90 - - - Psoriasis
ED31 - - - Burning feet syndrome
ED70 - - - - Alopecia or hair loss
ED80 - - - - - Acne
FA00 - - - Osteoarthritis of hip
FA01 - - - Osteoarthritis of knee
FA02 - - - Osteoarthritis of wrist or hand
FA20 - - - Rheumatoid arthritis
FA21 - - - Psoriatic arthritis
FA22 - - - Polymyalgia rheumatica
FA25 - - - Gout
FA32 - - - Disorders of patella
FA33.1 - - - - Discoid meniscus
FA33.4 - - - - Chronic instability of knee
FA70 - - - Spinal deformities
FA71 - - - Torticollis
FA72.Z - - - - Disorders of vertebra, unspecified
FA80 - - - Intervertebral disc degeneration
FA80.1 - - - - Intervertebral disc degeneration of cervical spine with prolapsed disc
FA80.9 - - - - Intervertebral disc degeneration of lumbar spine with prolapsed disc
FA81 - - - Spondylolysis
FA82 - - - Spinal stenosis
FA84 - - - Spondylolisthesis
FB32.1 - - - - Spontaneous rupture of muscle
FB32.4 - - - - Contracture of muscle
FB32.5 - - - - Muscle strain or sprain
FB40 - - - Tenosynovitis
FB40.4 - - - - Trigger finger
FB50 - - - Bursitis
FB53 - - - Shoulder lesions
FB53.0 - - - - Adhesive capsulitis of shoulder
FB53.1 - - - - Rotator cuff syndrome
FB54.3 - - - - Calcaneal spur
FB55.0 - - - - Medial epicondylitis of elbow
FB55.1 - - - - Lateral epicondylitis of elbow
FB55.2 - - - - Periarthritis of wrist
FB56.2 - - - - Myalgia
GA10 - - Endometriosis
GA18.0 - - - - Follicular cyst of ovary
GA20 - - - Menstrual cycle bleeding disorders
GA20.0 - - - - Amenorrhoea
GA20.10 - - - - - Frequent menstrual bleeding
GA20.11 - - - - - Infrequent menstrual bleeding
GA20.50 - - - - - Heavy menstrual bleeding
GA30.0 - - - Menopause
GA30.4 - - - Menopausal hot flush
GA31 - - Female infertility
GA34.2 - - - Female pelvic pain
GA34.3 - - - Dysmenorrhoea
GA34.4 - - - Premenstrual disturbances
GA34.6 - - - Female genital pain
GB04 - - Male infertility
GC08 - - - Urinary tract infection, site not specified
HA01.1 - - - Male erectile dysfunction
JA60 - - Excessive vomiting in pregnancy
MB22.7 - - - Tiredness
MB24.3 - - - Anxiety
MB24.5 - - - Depressed mood
MB24.F - - - Restlessness
MB24.H - - - Worry
MB47.3 - - - - Cramp or spasm
MB48 - - - Dizziness and giddiness
MB48.0 - - - - Vertigo
MB53 - - - - Hemiplegia
MC41 - - - Tinnitus
MC81.2 - - - - Palpitations
MD11.5 - - - - Dyspnoea
MD11.9 - - - - Nasal congestion
MD11.C - - - - Wheezing
MD12 - - - Cough
MD90.0 - - - - - Nausea
ME01 - - - - Abdominal distension
ME05.0 - - - - - Constipation
ME05.1 - - - - - Diarrhoea
ME65.1 - - - - Itching of skin
ME81 - - - Musculoskeletal chest pain
ME81.0 - - - - Intercostal pain
ME82 - - - Pain in joint
ME83 - - - Rheumatism, unspecified
ME84 - - - Spinal pain
ME84.0 - - - - Cervical spine pain
ME84.1 - - - - Thoracic spine pain
ME84.2 - - - - Low back pain
ME84.20 - - - - - Lumbago with sciatica
ME84.3 - - - - Sciatica
ME85 - - - Stiffness of joint
ME86.0 - - - - Symptom or complaint of the ankle
ME86.1 - - - - Symptom or complaint of the arm
ME86.2 - - - - Symptom or complaint of the back
ME86.4 - - - - Symptom or complaint of the elbow
ME86.6 - - - - Symptom or complaint of the foot or toe
ME86.7 - - - - Symptom or complaint of the hand or finger
ME86.8 - - - - Symptom or complaint of the hip
ME86.9 - - - - Symptom or complaint of the jaw
ME86.A - - - - Symptom or complaint of the knee
ME86.B - - - - Symptom or complaint of the leg or thigh
ME86.C - - - - Symptom or complaint of the neck
ME86.D - - - - Symptom or complaint of the shoulder
ME86.E - - - - Symptom or complaint of the wrist
MF32 - - - Menopausal symptom or complaint
MF33 - - - Premenstrual symptom or complaint
MF34 - - - Pregnancy symptom or complaint
MF40.00 - - - - - Pain in penis
MF41 - - - Symptom or complaint of male sexual function
MF50.2 - - - - Urinary incontinence
MF50.20 - - - - - Stress incontinence
MG22 - - - Fatigue
MG30 - - - - Chronic pain
MG30.10 - - - - - - Chronic cancer pain
MG30.20 - - - - - - Chronic post traumatic pain
MG30.5 - - - - - Chronic neuropathic pain
MG30.50 - - - - - - Chronic central neuropathic pain
other
Please Select
Please Select
1B40.0 - - - - Rheumatic arthritis, acute or subacute
1F00 - - Herpes simplex infections
1F00.01 - - - - Herpes simplex labialis
1F00.2 - - - Herpes simplex infection of central nervous system
3A71 - - Anaemia due to chronic disease
4A43.2 - - - Sjögren syndrome
4A44 - - Vasculitis
4A80.Z - - - Allergic or hypersensitivity disorders involving the respiratory tract, unspecified
5A00 - - - Hypothyroidism
5A11 - - - Type 2 diabetes mellitus
5A80.2 - - - - Polycystic ovary
5B80.0 - - - - - Overweight
5B81 - - - - Obesity
5C80.0 - - - - Hypercholesterolaemia
6A05 - - Attention deficit hyperactivity disorder
6A71 - - - Recurrent depressive disorder
6A80.0 - - - Prominent anxiety symptoms in mood episodes
6B41 - - Complex post traumatic stress disorder
6B60.2 - - - Dissociative neurological symptom disorder, with vertigo or dizziness
6B60.84 - - - - Dissociative neurological symptom disorder, with facial spasm
6B60.85 - - - - Dissociative neurological symptom disorder, with Parkinsonism
7A00 - - Chronic insomnia
7A80 - - Restless legs syndrome
8A00.0 - - - Parkinson disease
8A05 - - Tic disorders
8A40 - - Multiple sclerosis
8A60 - - Epilepsy due to structural or metabolic conditions or diseases
8A80 - - Migraine
8A80.0 - - - Migraine without aura
8A80.1 - - - Migraine with aura
8A81 - - Tension-type headache
8B11 - - - Cerebral ischaemic stroke
8B82.0 - - - - Trigeminal neuralgia
8B88.0 - - - - Bell palsy
8B93 - - - Radiculopathy
8B93.6 - - - - Radiculopathy due to intervertebral disc disorders
8C00 - - - Idiopathic progressive neuropathy
8C03.0 - - - - Diabetic polyneuropathy
8C10.0 - - - - Carpal tunnel syndrome
8C10.1 - - - - Lesion of ulnar nerve
8C10.2 - - - - Lesion of radial nerve
8C11.0 - - - - Lesion of sciatic nerve
8C11.00 - - - - - Sciatic nerve piriformis syndrome
8C12.0 - - - - Intercostal neuropathy
8C70 - - - Muscular dystrophy
8E43.0 - - - Neuropathic pain
8E43.00 - - - - Phantom limb syndrome
9A11 - - - Disorders of lacrimal drainage system
9A60 - - - Conjunctivitis
9C61 - - Glaucoma
AB00 - - - Acute otitis media
AB01 - - - Chronic otitis media
AB31.0 - - - Meniere disease
AB31.2 - - - Benign positional paroxysmal vertigo
BA00 - - Essential hypertension
BA04 - - Secondary hypertension
BD42 - - - Raynaud phenomenon
BD74.1 - - - Lower limb varicose veins
CA01 - - Acute sinusitis
CA08.0 - - - Allergic rhinitis
CA09.0 - - - Chronic rhinitis
CA20.1 - - - Chronic bronchitis
CA22 - - Chronic obstructive pulmonary disease
CA23 - - Asthma
DA0E.8 - - - Temporomandibular joint disorders
DA22 - - Gastro-oesophageal reflux disease
DB60 - - - Haemorrhoids
DD70 - - Crohn disease
DD71 - - Ulcerative colitis
DD91.0 - - - Irritable bowel syndrome
DD91.1 - - - Functional constipation
DD91.2 - - - Functional diarrhoea
DD91.3 - - - Functional bloating
EA80 - - - Atopic eczema
EA90 - - - Psoriasis
ED31 - - - Burning feet syndrome
ED70 - - - - Alopecia or hair loss
ED80 - - - - - Acne
FA00 - - - Osteoarthritis of hip
FA01 - - - Osteoarthritis of knee
FA02 - - - Osteoarthritis of wrist or hand
FA20 - - - Rheumatoid arthritis
FA21 - - - Psoriatic arthritis
FA22 - - - Polymyalgia rheumatica
FA25 - - - Gout
FA32 - - - Disorders of patella
FA33.1 - - - - Discoid meniscus
FA33.4 - - - - Chronic instability of knee
FA70 - - - Spinal deformities
FA71 - - - Torticollis
FA72.Z - - - - Disorders of vertebra, unspecified
FA80 - - - Intervertebral disc degeneration
FA80.1 - - - - Intervertebral disc degeneration of cervical spine with prolapsed disc
FA80.9 - - - - Intervertebral disc degeneration of lumbar spine with prolapsed disc
FA81 - - - Spondylolysis
FA82 - - - Spinal stenosis
FA84 - - - Spondylolisthesis
FB32.1 - - - - Spontaneous rupture of muscle
FB32.4 - - - - Contracture of muscle
FB32.5 - - - - Muscle strain or sprain
FB40 - - - Tenosynovitis
FB40.4 - - - - Trigger finger
FB50 - - - Bursitis
FB53 - - - Shoulder lesions
FB53.0 - - - - Adhesive capsulitis of shoulder
FB53.1 - - - - Rotator cuff syndrome
FB54.3 - - - - Calcaneal spur
FB55.0 - - - - Medial epicondylitis of elbow
FB55.1 - - - - Lateral epicondylitis of elbow
FB55.2 - - - - Periarthritis of wrist
FB56.2 - - - - Myalgia
GA10 - - Endometriosis
GA18.0 - - - - Follicular cyst of ovary
GA20 - - - Menstrual cycle bleeding disorders
GA20.0 - - - - Amenorrhoea
GA20.10 - - - - - Frequent menstrual bleeding
GA20.11 - - - - - Infrequent menstrual bleeding
GA20.50 - - - - - Heavy menstrual bleeding
GA30.0 - - - Menopause
GA30.4 - - - Menopausal hot flush
GA31 - - Female infertility
GA34.2 - - - Female pelvic pain
GA34.3 - - - Dysmenorrhoea
GA34.4 - - - Premenstrual disturbances
GA34.6 - - - Female genital pain
GB04 - - Male infertility
GC08 - - - Urinary tract infection, site not specified
HA01.1 - - - Male erectile dysfunction
JA60 - - Excessive vomiting in pregnancy
MB22.7 - - - Tiredness
MB24.3 - - - Anxiety
MB24.5 - - - Depressed mood
MB24.F - - - Restlessness
MB24.H - - - Worry
MB47.3 - - - - Cramp or spasm
MB48 - - - Dizziness and giddiness
MB48.0 - - - - Vertigo
MB53 - - - - Hemiplegia
MC41 - - - Tinnitus
MC81.2 - - - - Palpitations
MD11.5 - - - - Dyspnoea
MD11.9 - - - - Nasal congestion
MD11.C - - - - Wheezing
MD12 - - - Cough
MD90.0 - - - - - Nausea
ME01 - - - - Abdominal distension
ME05.0 - - - - - Constipation
ME05.1 - - - - - Diarrhoea
ME65.1 - - - - Itching of skin
ME81 - - - Musculoskeletal chest pain
ME81.0 - - - - Intercostal pain
ME82 - - - Pain in joint
ME83 - - - Rheumatism, unspecified
ME84 - - - Spinal pain
ME84.0 - - - - Cervical spine pain
ME84.1 - - - - Thoracic spine pain
ME84.2 - - - - Low back pain
ME84.20 - - - - - Lumbago with sciatica
ME84.3 - - - - Sciatica
ME85 - - - Stiffness of joint
ME86.0 - - - - Symptom or complaint of the ankle
ME86.1 - - - - Symptom or complaint of the arm
ME86.2 - - - - Symptom or complaint of the back
ME86.4 - - - - Symptom or complaint of the elbow
ME86.6 - - - - Symptom or complaint of the foot or toe
ME86.7 - - - - Symptom or complaint of the hand or finger
ME86.8 - - - - Symptom or complaint of the hip
ME86.9 - - - - Symptom or complaint of the jaw
ME86.A - - - - Symptom or complaint of the knee
ME86.B - - - - Symptom or complaint of the leg or thigh
ME86.C - - - - Symptom or complaint of the neck
ME86.D - - - - Symptom or complaint of the shoulder
ME86.E - - - - Symptom or complaint of the wrist
MF32 - - - Menopausal symptom or complaint
MF33 - - - Premenstrual symptom or complaint
MF34 - - - Pregnancy symptom or complaint
MF40.00 - - - - - Pain in penis
MF41 - - - Symptom or complaint of male sexual function
MF50.2 - - - - Urinary incontinence
MF50.20 - - - - - Stress incontinence
MG22 - - - Fatigue
MG30 - - - - Chronic pain
MG30.10 - - - - - - Chronic cancer pain
MG30.20 - - - - - - Chronic post traumatic pain
MG30.5 - - - - - Chronic neuropathic pain
MG30.50 - - - - - - Chronic central neuropathic pain
other
ICD code
Other - please specify
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9
Is the client receiving medication?
Is the client receiving medication?
Yes
No
Is the client receiving medication?
Is the client receiving medication?
Yes
No
Is the client receiving medication?
If yes, which medications?
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10
Are there side effects?
Are there side effects?
Yes
No
Are there side effects?
Are there side effects?
Yes
No
Are there side effects?
Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Intensity
Intensity
1
2
3
4
5
6
7
8
9
10
not applicable
Intensity (1 the lowest to 10 the highest. If not applicable, select "not applicable")
Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Frequency
Frequency
1
2
3
4
5
6
7
8
9
10
not applicable
Frequency (1 the lowest to 10 the highest. If not applicable, select "not applicable")
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11
Did the client receive any other treatments?
Did the client receive any other treatments?
Yes
No
Did the client receive any other treatments?
Did the client receive any other treatments?
Yes
No
Did the client receive any other treatments?
Acupuncture
Chinese Herbs
Hydrotherapy
Massage
Naturopathy
Osteopathy
Reflexology
Shiatsu
Tuina
Western Herbs
Acupuncture
Chinese Herbs
Hydrotherapy
Massage
Naturopathy
Osteopathy
Reflexology
Shiatsu
Tuina
Western Herbs
Specify
Other
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12
Were tests done? (blood, blood pressure, radiology,)
- Were tests done? (blood, blood pressure, radiology, etc.)
Yes
No
- Were tests done? (blood, blood pressure, radiology, etc.)
- Were tests done? (blood, blood pressure, radiology, etc.)
Yes
No
Were tests done? (blood, blood pressure, radiology, etc.)
Blood
Blood pressure
Radiology
Blood
Blood pressure
Radiology
Test 1
Ok
No ok
Ok
No ok
Results 1
Blood
Blood pressure
Radiology
Not applicable
Blood
Blood pressure
Radiology
Not applicable
Test 2
Ok
No ok
Ok
No ok
Result 2
Blood
Blood pressure
Radiology
Not applicable
Blood
Blood pressure
Radiology
Not applicable
Test 3
Ok
No ok
Ok
No ok
Results 3
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13
Did the client visit the emergency room for these reasons?
- Did the client visit the emergency room for these reasons?
Yes
No
- Did the client visit the emergency room for these reasons?
- Did the client visit the emergency room for these reasons?
Yes
No
- Did the client visit the emergency room for these reasons?
If so, please note
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14
Was the client hospitalized for these reasons?
Was the client hospitalized for these reasons?
Yes
No
Was the client hospitalized for these reasons?
Was the client hospitalized for these reasons?
Yes
No
Was the client hospitalized for these reasons?
If so, please note
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15
Was surgical intervention recommended?
Was surgical intervention recommended?
Yes
No
Was surgical intervention recommended?
Was surgical intervention recommended?
Yes
No
Was surgical intervention recommended?
Results
Yes
No
Not applicable
Results
Results
Yes
No
Not applicable
Did the client do it?
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16
Does the reason for coming have an effect on:
(1 the lowest to 10 the highest. If not applicable, select "not applicable")
Dailyactivities
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Rest
Ability at Work
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Ability at Work
Ability at Work
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Ability at Work
Sleep
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Sleep
Sleep
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Sleep
Apatite
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Apatite
Apatite
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Apatite
General Well Being
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General Well Being
General Well Being
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General Well Being
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17
Diagnosis
Your diagnosis as a caregiver in your professional expertise
Please Select
1B40.0 - - - - Rheumatic arthritis, acute or subacute
1F00 - - Herpes simplex infections
1F00.01 - - - - Herpes simplex labialis
1F00.2 - - - Herpes simplex infection of central nervous system
3A71 - - Anaemia due to chronic disease
4A43.2 - - - Sjögren syndrome
4A44 - - Vasculitis
4A80.Z - - - Allergic or hypersensitivity disorders involving the respiratory tract, unspecified
5A00 - - - Hypothyroidism
5A11 - - - Type 2 diabetes mellitus
5A80.2 - - - - Polycystic ovary
5B80.0 - - - - - Overweight
5B81 - - - - Obesity
5C80.0 - - - - Hypercholesterolaemia
6A05 - - Attention deficit hyperactivity disorder
6A71 - - - Recurrent depressive disorder
6A80.0 - - - Prominent anxiety symptoms in mood episodes
6B41 - - Complex post traumatic stress disorder
6B60.2 - - - Dissociative neurological symptom disorder, with vertigo or dizziness
6B60.84 - - - - Dissociative neurological symptom disorder, with facial spasm
6B60.85 - - - - Dissociative neurological symptom disorder, with Parkinsonism
7A00 - - Chronic insomnia
7A80 - - Restless legs syndrome
8A00.0 - - - Parkinson disease
8A05 - - Tic disorders
8A40 - - Multiple sclerosis
8A60 - - Epilepsy due to structural or metabolic conditions or diseases
8A80 - - Migraine
8A80.0 - - - Migraine without aura
8A80.1 - - - Migraine with aura
8A81 - - Tension-type headache
8B11 - - - Cerebral ischaemic stroke
8B82.0 - - - - Trigeminal neuralgia
8B88.0 - - - - Bell palsy
8B93 - - - Radiculopathy
8B93.6 - - - - Radiculopathy due to intervertebral disc disorders
8C00 - - - Idiopathic progressive neuropathy
8C03.0 - - - - Diabetic polyneuropathy
8C10.0 - - - - Carpal tunnel syndrome
8C10.1 - - - - Lesion of ulnar nerve
8C10.2 - - - - Lesion of radial nerve
8C11.0 - - - - Lesion of sciatic nerve
8C11.00 - - - - - Sciatic nerve piriformis syndrome
8C12.0 - - - - Intercostal neuropathy
8C70 - - - Muscular dystrophy
8E43.0 - - - Neuropathic pain
8E43.00 - - - - Phantom limb syndrome
9A11 - - - Disorders of lacrimal drainage system
9A60 - - - Conjunctivitis
9C61 - - Glaucoma
AB00 - - - Acute otitis media
AB01 - - - Chronic otitis media
AB31.0 - - - Meniere disease
AB31.2 - - - Benign positional paroxysmal vertigo
BA00 - - Essential hypertension
BA04 - - Secondary hypertension
BD42 - - - Raynaud phenomenon
BD74.1 - - - Lower limb varicose veins
CA01 - - Acute sinusitis
CA08.0 - - - Allergic rhinitis
CA09.0 - - - Chronic rhinitis
CA20.1 - - - Chronic bronchitis
CA22 - - Chronic obstructive pulmonary disease
CA23 - - Asthma
DA0E.8 - - - Temporomandibular joint disorders
DA22 - - Gastro-oesophageal reflux disease
DB60 - - - Haemorrhoids
DD70 - - Crohn disease
DD71 - - Ulcerative colitis
DD91.0 - - - Irritable bowel syndrome
DD91.1 - - - Functional constipation
DD91.2 - - - Functional diarrhoea
DD91.3 - - - Functional bloating
EA80 - - - Atopic eczema
EA90 - - - Psoriasis
ED31 - - - Burning feet syndrome
ED70 - - - - Alopecia or hair loss
ED80 - - - - - Acne
FA00 - - - Osteoarthritis of hip
FA01 - - - Osteoarthritis of knee
FA02 - - - Osteoarthritis of wrist or hand
FA20 - - - Rheumatoid arthritis
FA21 - - - Psoriatic arthritis
FA22 - - - Polymyalgia rheumatica
FA25 - - - Gout
FA32 - - - Disorders of patella
FA33.1 - - - - Discoid meniscus
FA33.4 - - - - Chronic instability of knee
FA70 - - - Spinal deformities
FA71 - - - Torticollis
FA72.Z - - - - Disorders of vertebra, unspecified
FA80 - - - Intervertebral disc degeneration
FA80.1 - - - - Intervertebral disc degeneration of cervical spine with prolapsed disc
FA80.9 - - - - Intervertebral disc degeneration of lumbar spine with prolapsed disc
FA81 - - - Spondylolysis
FA82 - - - Spinal stenosis
FA84 - - - Spondylolisthesis
FB32.1 - - - - Spontaneous rupture of muscle
FB32.4 - - - - Contracture of muscle
FB32.5 - - - - Muscle strain or sprain
FB40 - - - Tenosynovitis
FB40.4 - - - - Trigger finger
FB50 - - - Bursitis
FB53 - - - Shoulder lesions
FB53.0 - - - - Adhesive capsulitis of shoulder
FB53.1 - - - - Rotator cuff syndrome
FB54.3 - - - - Calcaneal spur
FB55.0 - - - - Medial epicondylitis of elbow
FB55.1 - - - - Lateral epicondylitis of elbow
FB55.2 - - - - Periarthritis of wrist
FB56.2 - - - - Myalgia
GA10 - - Endometriosis
GA18.0 - - - - Follicular cyst of ovary
GA20 - - - Menstrual cycle bleeding disorders
GA20.0 - - - - Amenorrhoea
GA20.10 - - - - - Frequent menstrual bleeding
GA20.11 - - - - - Infrequent menstrual bleeding
GA20.50 - - - - - Heavy menstrual bleeding
GA30.0 - - - Menopause
GA30.4 - - - Menopausal hot flush
GA31 - - Female infertility
GA34.2 - - - Female pelvic pain
GA34.3 - - - Dysmenorrhoea
GA34.4 - - - Premenstrual disturbances
GA34.6 - - - Female genital pain
GB04 - - Male infertility
GC08 - - - Urinary tract infection, site not specified
HA01.1 - - - Male erectile dysfunction
JA60 - - Excessive vomiting in pregnancy
MB22.7 - - - Tiredness
MB24.3 - - - Anxiety
MB24.5 - - - Depressed mood
MB24.F - - - Restlessness
MB24.H - - - Worry
MB47.3 - - - - Cramp or spasm
MB48 - - - Dizziness and giddiness
MB48.0 - - - - Vertigo
MB53 - - - - Hemiplegia
MC41 - - - Tinnitus
MC81.2 - - - - Palpitations
MD11.5 - - - - Dyspnoea
MD11.9 - - - - Nasal congestion
MD11.C - - - - Wheezing
MD12 - - - Cough
MD90.0 - - - - - Nausea
ME01 - - - - Abdominal distension
ME05.0 - - - - - Constipation
ME05.1 - - - - - Diarrhoea
ME65.1 - - - - Itching of skin
ME81 - - - Musculoskeletal chest pain
ME81.0 - - - - Intercostal pain
ME82 - - - Pain in joint
ME83 - - - Rheumatism, unspecified
ME84 - - - Spinal pain
ME84.0 - - - - Cervical spine pain
ME84.1 - - - - Thoracic spine pain
ME84.2 - - - - Low back pain
ME84.20 - - - - - Lumbago with sciatica
ME84.3 - - - - Sciatica
ME85 - - - Stiffness of joint
ME86.0 - - - - Symptom or complaint of the ankle
ME86.1 - - - - Symptom or complaint of the arm
ME86.2 - - - - Symptom or complaint of the back
ME86.4 - - - - Symptom or complaint of the elbow
ME86.6 - - - - Symptom or complaint of the foot or toe
ME86.7 - - - - Symptom or complaint of the hand or finger
ME86.8 - - - - Symptom or complaint of the hip
ME86.9 - - - - Symptom or complaint of the jaw
ME86.A - - - - Symptom or complaint of the knee
ME86.B - - - - Symptom or complaint of the leg or thigh
ME86.C - - - - Symptom or complaint of the neck
ME86.D - - - - Symptom or complaint of the shoulder
ME86.E - - - - Symptom or complaint of the wrist
MF32 - - - Menopausal symptom or complaint
MF33 - - - Premenstrual symptom or complaint
MF34 - - - Pregnancy symptom or complaint
MF40.00 - - - - - Pain in penis
MF41 - - - Symptom or complaint of male sexual function
MF50.2 - - - - Urinary incontinence
MF50.20 - - - - - Stress incontinence
MG22 - - - Fatigue
MG30 - - - - Chronic pain
MG30.10 - - - - - - Chronic cancer pain
MG30.20 - - - - - - Chronic post traumatic pain
MG30.5 - - - - - Chronic neuropathic pain
MG30.50 - - - - - - Chronic central neuropathic pain
Other
Please Select
Please Select
1B40.0 - - - - Rheumatic arthritis, acute or subacute
1F00 - - Herpes simplex infections
1F00.01 - - - - Herpes simplex labialis
1F00.2 - - - Herpes simplex infection of central nervous system
3A71 - - Anaemia due to chronic disease
4A43.2 - - - Sjögren syndrome
4A44 - - Vasculitis
4A80.Z - - - Allergic or hypersensitivity disorders involving the respiratory tract, unspecified
5A00 - - - Hypothyroidism
5A11 - - - Type 2 diabetes mellitus
5A80.2 - - - - Polycystic ovary
5B80.0 - - - - - Overweight
5B81 - - - - Obesity
5C80.0 - - - - Hypercholesterolaemia
6A05 - - Attention deficit hyperactivity disorder
6A71 - - - Recurrent depressive disorder
6A80.0 - - - Prominent anxiety symptoms in mood episodes
6B41 - - Complex post traumatic stress disorder
6B60.2 - - - Dissociative neurological symptom disorder, with vertigo or dizziness
6B60.84 - - - - Dissociative neurological symptom disorder, with facial spasm
6B60.85 - - - - Dissociative neurological symptom disorder, with Parkinsonism
7A00 - - Chronic insomnia
7A80 - - Restless legs syndrome
8A00.0 - - - Parkinson disease
8A05 - - Tic disorders
8A40 - - Multiple sclerosis
8A60 - - Epilepsy due to structural or metabolic conditions or diseases
8A80 - - Migraine
8A80.0 - - - Migraine without aura
8A80.1 - - - Migraine with aura
8A81 - - Tension-type headache
8B11 - - - Cerebral ischaemic stroke
8B82.0 - - - - Trigeminal neuralgia
8B88.0 - - - - Bell palsy
8B93 - - - Radiculopathy
8B93.6 - - - - Radiculopathy due to intervertebral disc disorders
8C00 - - - Idiopathic progressive neuropathy
8C03.0 - - - - Diabetic polyneuropathy
8C10.0 - - - - Carpal tunnel syndrome
8C10.1 - - - - Lesion of ulnar nerve
8C10.2 - - - - Lesion of radial nerve
8C11.0 - - - - Lesion of sciatic nerve
8C11.00 - - - - - Sciatic nerve piriformis syndrome
8C12.0 - - - - Intercostal neuropathy
8C70 - - - Muscular dystrophy
8E43.0 - - - Neuropathic pain
8E43.00 - - - - Phantom limb syndrome
9A11 - - - Disorders of lacrimal drainage system
9A60 - - - Conjunctivitis
9C61 - - Glaucoma
AB00 - - - Acute otitis media
AB01 - - - Chronic otitis media
AB31.0 - - - Meniere disease
AB31.2 - - - Benign positional paroxysmal vertigo
BA00 - - Essential hypertension
BA04 - - Secondary hypertension
BD42 - - - Raynaud phenomenon
BD74.1 - - - Lower limb varicose veins
CA01 - - Acute sinusitis
CA08.0 - - - Allergic rhinitis
CA09.0 - - - Chronic rhinitis
CA20.1 - - - Chronic bronchitis
CA22 - - Chronic obstructive pulmonary disease
CA23 - - Asthma
DA0E.8 - - - Temporomandibular joint disorders
DA22 - - Gastro-oesophageal reflux disease
DB60 - - - Haemorrhoids
DD70 - - Crohn disease
DD71 - - Ulcerative colitis
DD91.0 - - - Irritable bowel syndrome
DD91.1 - - - Functional constipation
DD91.2 - - - Functional diarrhoea
DD91.3 - - - Functional bloating
EA80 - - - Atopic eczema
EA90 - - - Psoriasis
ED31 - - - Burning feet syndrome
ED70 - - - - Alopecia or hair loss
ED80 - - - - - Acne
FA00 - - - Osteoarthritis of hip
FA01 - - - Osteoarthritis of knee
FA02 - - - Osteoarthritis of wrist or hand
FA20 - - - Rheumatoid arthritis
FA21 - - - Psoriatic arthritis
FA22 - - - Polymyalgia rheumatica
FA25 - - - Gout
FA32 - - - Disorders of patella
FA33.1 - - - - Discoid meniscus
FA33.4 - - - - Chronic instability of knee
FA70 - - - Spinal deformities
FA71 - - - Torticollis
FA72.Z - - - - Disorders of vertebra, unspecified
FA80 - - - Intervertebral disc degeneration
FA80.1 - - - - Intervertebral disc degeneration of cervical spine with prolapsed disc
FA80.9 - - - - Intervertebral disc degeneration of lumbar spine with prolapsed disc
FA81 - - - Spondylolysis
FA82 - - - Spinal stenosis
FA84 - - - Spondylolisthesis
FB32.1 - - - - Spontaneous rupture of muscle
FB32.4 - - - - Contracture of muscle
FB32.5 - - - - Muscle strain or sprain
FB40 - - - Tenosynovitis
FB40.4 - - - - Trigger finger
FB50 - - - Bursitis
FB53 - - - Shoulder lesions
FB53.0 - - - - Adhesive capsulitis of shoulder
FB53.1 - - - - Rotator cuff syndrome
FB54.3 - - - - Calcaneal spur
FB55.0 - - - - Medial epicondylitis of elbow
FB55.1 - - - - Lateral epicondylitis of elbow
FB55.2 - - - - Periarthritis of wrist
FB56.2 - - - - Myalgia
GA10 - - Endometriosis
GA18.0 - - - - Follicular cyst of ovary
GA20 - - - Menstrual cycle bleeding disorders
GA20.0 - - - - Amenorrhoea
GA20.10 - - - - - Frequent menstrual bleeding
GA20.11 - - - - - Infrequent menstrual bleeding
GA20.50 - - - - - Heavy menstrual bleeding
GA30.0 - - - Menopause
GA30.4 - - - Menopausal hot flush
GA31 - - Female infertility
GA34.2 - - - Female pelvic pain
GA34.3 - - - Dysmenorrhoea
GA34.4 - - - Premenstrual disturbances
GA34.6 - - - Female genital pain
GB04 - - Male infertility
GC08 - - - Urinary tract infection, site not specified
HA01.1 - - - Male erectile dysfunction
JA60 - - Excessive vomiting in pregnancy
MB22.7 - - - Tiredness
MB24.3 - - - Anxiety
MB24.5 - - - Depressed mood
MB24.F - - - Restlessness
MB24.H - - - Worry
MB47.3 - - - - Cramp or spasm
MB48 - - - Dizziness and giddiness
MB48.0 - - - - Vertigo
MB53 - - - - Hemiplegia
MC41 - - - Tinnitus
MC81.2 - - - - Palpitations
MD11.5 - - - - Dyspnoea
MD11.9 - - - - Nasal congestion
MD11.C - - - - Wheezing
MD12 - - - Cough
MD90.0 - - - - - Nausea
ME01 - - - - Abdominal distension
ME05.0 - - - - - Constipation
ME05.1 - - - - - Diarrhoea
ME65.1 - - - - Itching of skin
ME81 - - - Musculoskeletal chest pain
ME81.0 - - - - Intercostal pain
ME82 - - - Pain in joint
ME83 - - - Rheumatism, unspecified
ME84 - - - Spinal pain
ME84.0 - - - - Cervical spine pain
ME84.1 - - - - Thoracic spine pain
ME84.2 - - - - Low back pain
ME84.20 - - - - - Lumbago with sciatica
ME84.3 - - - - Sciatica
ME85 - - - Stiffness of joint
ME86.0 - - - - Symptom or complaint of the ankle
ME86.1 - - - - Symptom or complaint of the arm
ME86.2 - - - - Symptom or complaint of the back
ME86.4 - - - - Symptom or complaint of the elbow
ME86.6 - - - - Symptom or complaint of the foot or toe
ME86.7 - - - - Symptom or complaint of the hand or finger
ME86.8 - - - - Symptom or complaint of the hip
ME86.9 - - - - Symptom or complaint of the jaw
ME86.A - - - - Symptom or complaint of the knee
ME86.B - - - - Symptom or complaint of the leg or thigh
ME86.C - - - - Symptom or complaint of the neck
ME86.D - - - - Symptom or complaint of the shoulder
ME86.E - - - - Symptom or complaint of the wrist
MF32 - - - Menopausal symptom or complaint
MF33 - - - Premenstrual symptom or complaint
MF34 - - - Pregnancy symptom or complaint
MF40.00 - - - - - Pain in penis
MF41 - - - Symptom or complaint of male sexual function
MF50.2 - - - - Urinary incontinence
MF50.20 - - - - - Stress incontinence
MG22 - - - Fatigue
MG30 - - - - Chronic pain
MG30.10 - - - - - - Chronic cancer pain
MG30.20 - - - - - - Chronic post traumatic pain
MG30.5 - - - - - Chronic neuropathic pain
MG30.50 - - - - - - Chronic central neuropathic pain
Other
ICD code
Please Select
SA50 - - - - - Dysphagia disorder (TM1)
SA51 - - - - - Stomach ache disorder (TM1)
SA52 - - - - - Epigastric distension disorder (TM1)
SA55 - - - - - Diarrhea disorder (TM1)
SA57 - - - - - Constipation disorder (TM1)
SA58 - - - - - Abdominal pain disorder (TM1)
SA7Z - - - - - - Cough disorders (TM1), unspecified
SA81 - - - - - Wheezing disorder (TM1)
SB0B - - - - - Impotence disorder (TM1)
SB0C - - - - - Male infertility disorder (TM1)
SB7A - - - - - Herpes zoster disorder (TM1)
SB7B - - - - - Interior haemorrhoid disorder (TM1)
SB80 - - - - - - - Advanced menstruation disorder (TM1)
SB81 - - - - - - - Delayed menstruation disorder (TM1)
SB82 - - - - - - - Irregular menstruation disorders (TM1)
SB8Z - - - - - - - Menstruation cycle disorders (TM1), unspecified
SB90 - - - - - - Menorrhagia disorder (TM1)
SB93 - - - - - - Metrorrhagia disorder (TM1)
SB94 - - - - - - Amenorrhea disorder (TM1)
SB95 - - - - - - Menopausal disorder (TM1)
SB96 - - - - - - Dysmenorrhea disorder (TM1)
SC00 - - - - - - Morning sickness disorder (TM1)
SC20 - - - - - - Leukorrhea disorder (TM1)
SC22 - - - - - - Infertility disorder (TM1)
SC60 - - - - - Muscle spasm disorder (TM1)
SC61 - - - - - Lumbago disorder (TM1)
SC6Z - - - - - Bone, joint and muscle system disorders (TM1), unspecified
SC75 - - - - - Tinnitus disorder (TM1)
SC90 - - - - - Allergic rhinitis disorder (TM1)
SC91 - - - - - Nasal sinusitis disorder (TM1)
SD00 - - - - - Facial paralysis disorder (TM1)
SD10 - - - - - - Migraine disorder (TM1)
SD22 - - - - - Vertigo disorder (TM1)
SD82 - - - - Depression disorder (TM1)
SD84 - - - - Insomnia disorder (TM1)
SD8Z - - - - Mental and emotional disorders (TM1), unspecified
SE70 - - - - Yang pattern (TM1)
SE71 - - - - Yin pattern (TM1)
SE72 - - - - Heat pattern (TM1)
SE73 - - - - Cold pattern (TM1)
SE80 - - - - Wind factor pattern (TM1)
SE82 - - - - Dampness factor pattern (TM1)
SE83 - - - - Dryness factor pattern (TM1)
SE84 - - - - Fire-heat factor pattern (TM1)
SE90 - - - - - Qi deficiency pattern (TM1)
SE91 - - - - - Qi stagnation pattern (TM1)
SE93 - - - - - Qi sinking pattern (TM1)
SF00 - - - - - Blood deficiency pattern (TM1)
SF01 - - - - - Blood stasis pattern (TM1)
SF02 - - - - - Blood heat pattern (TM1)
SF13 - - - - - Damp phlegm pattern (TM1)
SF50 - - - - - Liver yin deficiency pattern (TM1)
SF52 - - - - - Liver yang ascendant hyperactivity pattern (TM1)
SF54 - - - - - Liver blood deficiency pattern (TM1)
SF55 - - - - - Liver depression and blood stasis pattern (TM1)
SF56 - - - - - Liver wind stirring the interior pattern (TM1)
SF57 - - - - - Liver qi stagnation pattern (TM1)
SF58 - - - - - Liver fire flaming upward pattern (TM1)
SF59 - - - - - Liver heat stirring wind pattern (TM1)
SF5A - - - - - Liver-gallbladder dampness-heat pattern (TM1)
SF5B - - - - - Liver meridian dampness-heat pattern (TM1)
SF5C - - - - - Liver meridian cold stagnation pattern (TM1)
SF5H - - - - - Liver and kidney yin deficiency pattern (TM1)
SF5J - - - - - Disharmony of liver and spleen systems pattern (TM1)
SF5K - - - - - Disharmony of liver and stomach systems pattern (TM1)
SF5L - - - - - Liver fire invading the stomach system pattern (TM1)
SF5M - - - - - Liver fire invading the lung system pattern (TM1)
SF60 - - - - - Heart qi deficiency pattern (TM1)
SF61 - - - - - Heart blood deficiency pattern (TM1)
SF63 - - - - - Heart meridian obstruction pattern (TM1)
SF64 - - - - - Heart yin deficiency pattern (TM1)
SF66 - - - - - Heart yang deficiency pattern (TM1)
SF68 - - - - - Heart fire flaming upward pattern (TM1)
SF69 - - - - - Fire harassing heart spirit pattern (TM1)
SF6D - - - - - Small intestine qi stagnation pattern (TM1)
SF6E - - - - - Small intestine excess heat pattern (TM1)
SF6G - - - - - Heart and liver blood deficiency pattern (TM1)
SF6J - - - - - Heart and spleen systems deficiency pattern (TM1)
SF6L - - - - - Heart and kidney systems disharmony pattern (TM1)
SF70 - - - - - Spleen qi deficiency pattern (TM1)
SF71 - - - - - Spleen qi sinking pattern (TM1)
SF74 - - - - - Spleen failing to control the blood pattern (TM1)
SF75 - - - - - Spleen deficiency and blood depletion pattern (TM1)
SF77 - - - - - Spleen yang deficiency pattern (TM1)
SF79 - - - - - Spleen deficiency with dampness accumulation pattern (TM1)
SF7B - - - - - Cold-dampness encumbering the spleen system pattern (TM1)
SF7C - - - - - Stomach qi deficiency pattern (TM1)
SF7D - - - - - Stomach qi uprising pattern (TM1)
SF7E - - - - - Stomach yin deficiency pattern (TM1)
SF7F - - - - - Stomach heat pattern (TM1)
SF7G - - - - - Dampness in the intestines pattern (TM1)
SF7H - - - - - Cold invading the stomach system pattern (TM1)
SF7L - - - - - Lung and spleen deficiency pattern (TM1)
SF7M - - - - - Spleen and kidney yang deficiency pattern (TM1)
SF80 - - - - - Lung qi deficiency pattern (TM1)
SF81 - - - - - Lung yin deficiency pattern (TM1)
SF82 - - - - - Lung and kidney yin deficiency pattern (TM1)
SF83 - - - - - Lung qi and yin deficiency pattern (TM1)
SF85 - - - - - Cold phlegm obstructing the lung pattern (TM1)
SF86 - - - - - Turbid phlegm accumulation in the lung pattern (TM1)
SF89 - - - - - Phlegm heat obstructing the lung pattern (TM1)
SF8D - - - - - Dryness invading the lung pattern (TM1)
SF8F - - - - - Large intestine excess heat pattern (TM1)
SF8G - - - - - Large intestine dampness heat pattern (TM1)
SF90 - - - - - Kidney qi deficiency pattern (TM1)
SF91 - - - - - Kidney failing to receive qi pattern (TM1)
SF92 - - - - - Kidney qi deficiency with water retention pattern (TM1)
SF93 - - - - - Kidney yin deficiency pattern (TM1)
SF94 - - - - - Kidney yin and yang deficiency pattern (TM1)
SF97 - - - - - Kidney yang deficiency pattern (TM1)
SF9B - - - - - Dampness-heat in the uterus pattern (TM1)
SF9C - - - - - Cold stagnation in the uterus pattern (TM1)
SF9G - - - - - Bladder dampness-heat pattern (TM1)
SF9J - - - - - Bladder deficiency cold pattern (TM1)
SG20 - - - - - Lung meridian pattern (TM1)
SG21 - - - - - Large intestine meridian pattern (TM1)
SG22 - - - - - Stomach meridian pattern (TM1)
SG23 - - - - - Spleen meridian pattern (TM1)
SG24 - - - - - Heart meridian pattern (TM1)
SG25 - - - - - Small intestine meridian pattern (TM1)
SG26 - - - - - Bladder meridian pattern (TM1)
SG27 - - - - - Kidney meridian pattern (TM1)
SG28 - - - - - Pericardium meridian pattern (TM1)
SG29 - - - - - Triple energizer meridian pattern (TM1)
SG2A - - - - - Gallbladder meridian pattern (TM1)
SG2B - - - - - Liver meridian pattern (TM1)
SG30 - - - - - Governor vessel pattern (TM1)
SG31 - - - - - Conception vessel pattern (TM1)
SG32 - - - - - Yin heel vessel pattern (TM1)
SG33 - - - - - Yang heel vessel pattern (TM1)
SG34 - - - - - Yin link vessel pattern (TM1)
SG35 - - - - - Yang link vessel pattern (TM1)
SG37 - - - - - Belt vessel pattern (TM1)
Other
Please Select
Please Select
SA50 - - - - - Dysphagia disorder (TM1)
SA51 - - - - - Stomach ache disorder (TM1)
SA52 - - - - - Epigastric distension disorder (TM1)
SA55 - - - - - Diarrhea disorder (TM1)
SA57 - - - - - Constipation disorder (TM1)
SA58 - - - - - Abdominal pain disorder (TM1)
SA7Z - - - - - - Cough disorders (TM1), unspecified
SA81 - - - - - Wheezing disorder (TM1)
SB0B - - - - - Impotence disorder (TM1)
SB0C - - - - - Male infertility disorder (TM1)
SB7A - - - - - Herpes zoster disorder (TM1)
SB7B - - - - - Interior haemorrhoid disorder (TM1)
SB80 - - - - - - - Advanced menstruation disorder (TM1)
SB81 - - - - - - - Delayed menstruation disorder (TM1)
SB82 - - - - - - - Irregular menstruation disorders (TM1)
SB8Z - - - - - - - Menstruation cycle disorders (TM1), unspecified
SB90 - - - - - - Menorrhagia disorder (TM1)
SB93 - - - - - - Metrorrhagia disorder (TM1)
SB94 - - - - - - Amenorrhea disorder (TM1)
SB95 - - - - - - Menopausal disorder (TM1)
SB96 - - - - - - Dysmenorrhea disorder (TM1)
SC00 - - - - - - Morning sickness disorder (TM1)
SC20 - - - - - - Leukorrhea disorder (TM1)
SC22 - - - - - - Infertility disorder (TM1)
SC60 - - - - - Muscle spasm disorder (TM1)
SC61 - - - - - Lumbago disorder (TM1)
SC6Z - - - - - Bone, joint and muscle system disorders (TM1), unspecified
SC75 - - - - - Tinnitus disorder (TM1)
SC90 - - - - - Allergic rhinitis disorder (TM1)
SC91 - - - - - Nasal sinusitis disorder (TM1)
SD00 - - - - - Facial paralysis disorder (TM1)
SD10 - - - - - - Migraine disorder (TM1)
SD22 - - - - - Vertigo disorder (TM1)
SD82 - - - - Depression disorder (TM1)
SD84 - - - - Insomnia disorder (TM1)
SD8Z - - - - Mental and emotional disorders (TM1), unspecified
SE70 - - - - Yang pattern (TM1)
SE71 - - - - Yin pattern (TM1)
SE72 - - - - Heat pattern (TM1)
SE73 - - - - Cold pattern (TM1)
SE80 - - - - Wind factor pattern (TM1)
SE82 - - - - Dampness factor pattern (TM1)
SE83 - - - - Dryness factor pattern (TM1)
SE84 - - - - Fire-heat factor pattern (TM1)
SE90 - - - - - Qi deficiency pattern (TM1)
SE91 - - - - - Qi stagnation pattern (TM1)
SE93 - - - - - Qi sinking pattern (TM1)
SF00 - - - - - Blood deficiency pattern (TM1)
SF01 - - - - - Blood stasis pattern (TM1)
SF02 - - - - - Blood heat pattern (TM1)
SF13 - - - - - Damp phlegm pattern (TM1)
SF50 - - - - - Liver yin deficiency pattern (TM1)
SF52 - - - - - Liver yang ascendant hyperactivity pattern (TM1)
SF54 - - - - - Liver blood deficiency pattern (TM1)
SF55 - - - - - Liver depression and blood stasis pattern (TM1)
SF56 - - - - - Liver wind stirring the interior pattern (TM1)
SF57 - - - - - Liver qi stagnation pattern (TM1)
SF58 - - - - - Liver fire flaming upward pattern (TM1)
SF59 - - - - - Liver heat stirring wind pattern (TM1)
SF5A - - - - - Liver-gallbladder dampness-heat pattern (TM1)
SF5B - - - - - Liver meridian dampness-heat pattern (TM1)
SF5C - - - - - Liver meridian cold stagnation pattern (TM1)
SF5H - - - - - Liver and kidney yin deficiency pattern (TM1)
SF5J - - - - - Disharmony of liver and spleen systems pattern (TM1)
SF5K - - - - - Disharmony of liver and stomach systems pattern (TM1)
SF5L - - - - - Liver fire invading the stomach system pattern (TM1)
SF5M - - - - - Liver fire invading the lung system pattern (TM1)
SF60 - - - - - Heart qi deficiency pattern (TM1)
SF61 - - - - - Heart blood deficiency pattern (TM1)
SF63 - - - - - Heart meridian obstruction pattern (TM1)
SF64 - - - - - Heart yin deficiency pattern (TM1)
SF66 - - - - - Heart yang deficiency pattern (TM1)
SF68 - - - - - Heart fire flaming upward pattern (TM1)
SF69 - - - - - Fire harassing heart spirit pattern (TM1)
SF6D - - - - - Small intestine qi stagnation pattern (TM1)
SF6E - - - - - Small intestine excess heat pattern (TM1)
SF6G - - - - - Heart and liver blood deficiency pattern (TM1)
SF6J - - - - - Heart and spleen systems deficiency pattern (TM1)
SF6L - - - - - Heart and kidney systems disharmony pattern (TM1)
SF70 - - - - - Spleen qi deficiency pattern (TM1)
SF71 - - - - - Spleen qi sinking pattern (TM1)
SF74 - - - - - Spleen failing to control the blood pattern (TM1)
SF75 - - - - - Spleen deficiency and blood depletion pattern (TM1)
SF77 - - - - - Spleen yang deficiency pattern (TM1)
SF79 - - - - - Spleen deficiency with dampness accumulation pattern (TM1)
SF7B - - - - - Cold-dampness encumbering the spleen system pattern (TM1)
SF7C - - - - - Stomach qi deficiency pattern (TM1)
SF7D - - - - - Stomach qi uprising pattern (TM1)
SF7E - - - - - Stomach yin deficiency pattern (TM1)
SF7F - - - - - Stomach heat pattern (TM1)
SF7G - - - - - Dampness in the intestines pattern (TM1)
SF7H - - - - - Cold invading the stomach system pattern (TM1)
SF7L - - - - - Lung and spleen deficiency pattern (TM1)
SF7M - - - - - Spleen and kidney yang deficiency pattern (TM1)
SF80 - - - - - Lung qi deficiency pattern (TM1)
SF81 - - - - - Lung yin deficiency pattern (TM1)
SF82 - - - - - Lung and kidney yin deficiency pattern (TM1)
SF83 - - - - - Lung qi and yin deficiency pattern (TM1)
SF85 - - - - - Cold phlegm obstructing the lung pattern (TM1)
SF86 - - - - - Turbid phlegm accumulation in the lung pattern (TM1)
SF89 - - - - - Phlegm heat obstructing the lung pattern (TM1)
SF8D - - - - - Dryness invading the lung pattern (TM1)
SF8F - - - - - Large intestine excess heat pattern (TM1)
SF8G - - - - - Large intestine dampness heat pattern (TM1)
SF90 - - - - - Kidney qi deficiency pattern (TM1)
SF91 - - - - - Kidney failing to receive qi pattern (TM1)
SF92 - - - - - Kidney qi deficiency with water retention pattern (TM1)
SF93 - - - - - Kidney yin deficiency pattern (TM1)
SF94 - - - - - Kidney yin and yang deficiency pattern (TM1)
SF97 - - - - - Kidney yang deficiency pattern (TM1)
SF9B - - - - - Dampness-heat in the uterus pattern (TM1)
SF9C - - - - - Cold stagnation in the uterus pattern (TM1)
SF9G - - - - - Bladder dampness-heat pattern (TM1)
SF9J - - - - - Bladder deficiency cold pattern (TM1)
SG20 - - - - - Lung meridian pattern (TM1)
SG21 - - - - - Large intestine meridian pattern (TM1)
SG22 - - - - - Stomach meridian pattern (TM1)
SG23 - - - - - Spleen meridian pattern (TM1)
SG24 - - - - - Heart meridian pattern (TM1)
SG25 - - - - - Small intestine meridian pattern (TM1)
SG26 - - - - - Bladder meridian pattern (TM1)
SG27 - - - - - Kidney meridian pattern (TM1)
SG28 - - - - - Pericardium meridian pattern (TM1)
SG29 - - - - - Triple energizer meridian pattern (TM1)
SG2A - - - - - Gallbladder meridian pattern (TM1)
SG2B - - - - - Liver meridian pattern (TM1)
SG30 - - - - - Governor vessel pattern (TM1)
SG31 - - - - - Conception vessel pattern (TM1)
SG32 - - - - - Yin heel vessel pattern (TM1)
SG33 - - - - - Yang heel vessel pattern (TM1)
SG34 - - - - - Yin link vessel pattern (TM1)
SG35 - - - - - Yang link vessel pattern (TM1)
SG37 - - - - - Belt vessel pattern (TM1)
Other
Chinese medicine code
Other (please specify)
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What treatment methods will be used?
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No
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Please Select
Yes
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Are you planning to use acupuncture?
Therapeutic principle of acupuncture
Move Qi & Blood in Lung Meridian
Move Qi & Blood in Large Intestine Meridian
Move Qi & Blood in Stomach Meridian
Move Qi & Blood in Spleen Meridian
Move Qi & Blood in Heart Meridian
Move Qi & Blood in Small Intestine Meridian
Move Qi & Blood in Bladder Meridian
Move Qi & Blood in Kidney Meridian
Move Qi & Blood in Pericardium Meridian
Move Qi & Blood in Triple Heater Meridian
Move Qi & Blood in Gall Bladder Meridian
Move Qi & Blood in Liver Meridian
Disperse Dampness
Disperse Phlegm
Disperse Cold
Disperse Heat
Disperse Fire
Disperse Wind
Tonify Qi
Tonify Blood
Tonify Yin
Tonify Yang
Lower Yang
Lower Qi
Rise Qi
Move Qi Stagnation
Moisten Dryness
Warm Yang
Therapeutic principle of acupuncture
Therapeutic principle of acupuncture
Move Qi & Blood in Lung Meridian
Move Qi & Blood in Large Intestine Meridian
Move Qi & Blood in Stomach Meridian
Move Qi & Blood in Spleen Meridian
Move Qi & Blood in Heart Meridian
Move Qi & Blood in Small Intestine Meridian
Move Qi & Blood in Bladder Meridian
Move Qi & Blood in Kidney Meridian
Move Qi & Blood in Pericardium Meridian
Move Qi & Blood in Triple Heater Meridian
Move Qi & Blood in Gall Bladder Meridian
Move Qi & Blood in Liver Meridian
Disperse Dampness
Disperse Phlegm
Disperse Cold
Disperse Heat
Disperse Fire
Disperse Wind
Tonify Qi
Tonify Blood
Tonify Yin
Tonify Yang
Lower Yang
Lower Qi
Rise Qi
Move Qi Stagnation
Moisten Dryness
Warm Yang
Therapeutic principle of acupuncture
What treatment methods will be used 2
Acupuncture
Chinese Herbs
Hydrotherapy
Massage
Naturopathy
Osteopathy
Reflexology
Shiatsu
Tuina
Western Herbs
What treatment methods will be used 2
What treatment methods will be used 2
Acupuncture
Chinese Herbs
Hydrotherapy
Massage
Naturopathy
Osteopathy
Reflexology
Shiatsu
Tuina
Western Herbs
What treatment methods will be used 2
Therapeutic principle 2
What treatment methods will be used 3
Acupuncture
Chinese Herbs
Hydrotherapy
Massage
Naturopathy
Osteopathy
Reflexology
Shiatsu
Tuina
Western Herbs
What treatment methods will be used 3
What treatment methods will be used 3
Acupuncture
Chinese Herbs
Hydrotherapy
Massage
Naturopathy
Osteopathy
Reflexology
Shiatsu
Tuina
Western Herbs
What treatment methods will be used 3
Therapeutic principle 3
Please Select
Chinese Herbs
Western Herbs
None
Please Select
Please Select
Chinese Herbs
Western Herbs
None
Were herbs recommended?
Name of Formula / Herbs
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