Initial Acupuncture Visit

Administration & Consent

Patient Name: [Patient Name]

Date of Visit:

Practitioner Name:

Allergies:

Current Medications / Supplements:

Relevant Medical History:

Contraindications (pregnancy, pacemaker, bleeding disorder, anticoagulants, etc.):

Informed Consent Obtained:

S — Subjective

Chief Complaint & History

Chief Complaint (CC):

Date of CC onset:

Severity of CC:

Timing of CC (am, afternoon, pm, night):

History of Present Illness:

Other symptoms & signs:

Systemic & Lifestyle Review

Stress level & Management:

Sleep pattern:

Energy level:

Hot or cold preference:

Perspiration:

Thirst & Appetite:

Recent dietary changes:

Urination:

Bowel movement:

Menstruation (LMP, regularity, length, color, amount, clots, cramps):

Pregnancy status:

Yes (weeks: ___)

O — Objective

Physical Assessment

Patient Demeanor:

Complexion / facial color (面色):

Vitals

Blood Pressure

Systolic · mmHg

Diastolic · mmHg

Heart rate · bpm

Anthropometrics

Weight · kg

KG LB

Height · cm

CM FT/IN

Temperature · °C

°C °F

Notes

Pain Assessment (Numeric Rating Scale)

Pain Score

On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your pain right now?

012345678910

Pain context

Body site

Search Body site

Laterality

Select laterality...

Pain context

Current

Related condition

Search Related condition

Status

Active

Notes

Document quality, relief factors, and aggravating factors...

TCM Diagnostics (Tongue & Pulse)

Tongue proper (color, shape):

Tongue coating (color, thickness, moisture):

Sublingual veins:

Overall pulse quality (rate, depth, strength, rhythm — e.g., wiry, slippery, thin, rapid):

Pulse – Left (Cun HT, Guan LV, Chi KI):

Pulse – Right (Cun LU, Guan SP, Chi KI):

Sensory Organs (Eyes, Nose, Ears, Mouth):

A — Assessment

TCM Pattern Differentiation (辨证):

Eight Principles (yin/yang, interior/exterior, cold/heat, deficiency/excess):

Zang-Fu Pattern:

Treatment Principle (治法):

Biomedical / Western Impression:

P — Plan

Acupuncture Treatment Log

Acupoints selected & Technique (tonify/drain, depth, angle):

Number / gauge / length of needles:

Adjunct modalities:

Moxa

Cupping

E-stim

Auricular

Gua sha

Other: ___

Needle retention time (minutes):

Patient tolerance & response — during session:

Patient response — post-session / discharge:

Adverse events (bruising, dizziness, syncope, none):

Bruising

Dizziness

Syncope

None

Follow-Up

Summary of care recommendations:

Acupuncture treatment plan:

Home care / lifestyle / dietary advice:

Next consultation interval:

ND - Initial Acupuncture Visit

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