|Date: / /||Name :||File#||Age :||Gender :|
|S||BP :||/||HR :||/m||Temp :||Height :||Weight :|
|Chief Complaints. Responds to Last TX :|
|Digestion :||A.P :||Sleeping :||Energy :||Stress :|
|BM :||Frequency :||Quality :||Color :||Smell :|
|Urination :||Frequency :||Amount :||Color :||Smell :|
|Pain Level: /10 Severity : Minimal / Slight / Moderate / Severe Frequency : Occasional / Intermittent / Frequent / Constant|
|Pharmacological Assessments (Herb-Drug Interaction etc.)|
|O||Physical Exam (ROS, HEENT, Palpation & ROM, Ortho / Neuro, Adbominal Exam)|
|A||Tongue & Coating||Body :||Color :||Coating :||Color :|
|Shape :||Shape :|
|(Only if the patient brings in)|
|(Zang Fu / Syndrome)|
|ICD 10 Code|
|(97801 / 97811)|
|Name & Signature|
Hi I am the student Intern, My name is Tian and today I will be doing the your Intake.
May I have your 1.Name 2.Age 3.Height 4.weight 5.temp 6.blood pressureDid you cough or depends on weather?
1.Today do you have any health concerns or symptoms, you want me to pay attention How long did you have these symptoms? Days, months, years? Is pain for that area?What do you do for your pain? Did you do anything for that? Take medications?See doctor? What did the doctor say?
- Now I will ask some general question
- Sleep diet or appetite lot or less time/day mouth feel sour or bitter
- 3.Bowel movement stool soft hard firm constipation
- Urine function wake up at night to urin time/day color
3.How’s your hearing? Ring or noise How’s your vision? Blurry or light
Dose anyone at home have the same sickness?
4.FEMALES ONLY: When was your last period? Start date? Is it regular, delayed or irregular?