Case Taking

Chief concern, modalities, concomitants, generals, mental/emotional themes, cravings/aversions, thermal state, sleep, dreams, and menses if relevant.

Timeline, prior remedies, aggravations, direction of cure, and remedy response monitoring.

Chief complaint:

Onset:

Location:

Sensation:

Modalities - better:

Modalities - worse:

Concomitants:

Thermal preference:

Thirst / appetite:

Sleep / dreams:

Mental / emotional state:

Generalities:

Past history:

Family history:

Remedy / potency / repetition:

Plan and Follow-Up

Focus	Documentation
Assessment	Clinical impression, pattern or matrix priorities, red flags, patient goals, and uncertainty. Clinical impression: Priority concerns / red flags: Patient goals:
Recommendations	Nutrition, lifestyle, supplements, labs, education, referrals, and consent-sensitive items. Plan / recommendations: Labs / referrals: Education / consent:
Monitoring	Response markers, adverse-effect monitoring, reassessment cadence, and escalation criteria. Monitoring markers: Follow-up interval: Escalation criteria:

Focus

Documentation

Assessment

Clinical impression, pattern or matrix priorities, red flags, patient goals, and uncertainty.

Clinical impression:

Priority concerns / red flags:

Patient goals:

Recommendations

Nutrition, lifestyle, supplements, labs, education, referrals, and consent-sensitive items.

Plan / recommendations:

Labs / referrals:

Education / consent:

Monitoring

Response markers, adverse-effect monitoring, reassessment cadence, and escalation criteria.

Monitoring markers:

Follow-up interval:

Escalation criteria: