OMC Follow-up Intake

  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 :    
Western Diagnosis                
(Only if the patient brings in)                
TCM Diagnosis                
(Zang Fu / Syndrome)                
ICD 10 Code                
P Treatment Plan                
Points Treatment                
(97801 / 97811)                
Herbal Treatment                
Home Exercise                
Prognosis /                
Clinic Supervisor                
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?

  1. Now I will ask some general question
  2. Sleep diet or appetite lot or less time/day mouth feel sour or bitter
  3. 3.Bowel movement  stool  soft  hard  firm  constipation
  4. 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?