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TCM Clinic

Constitutional intake, pattern differentiation and treatment plan, treatment session records, herbal prescriptions, and course completion follow-ups for Traditional Chinese Medicine clinics and licensed TCM practitioners

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Patient Health & Constitution Record


This is your standing health record with our clinic — one copy that you and your practitioner keep current across your whole course of care. It is not tied to any single visit. Update it whenever your constitution, medications, or health status changes, and we will always be treating you from the right picture.

Patient Details
Full name:
Date of birth:
Phone:
Email:
Emergency contact (name & phone):
Patient since:

Constitution Profile (體質)
Predominant constitutional type(s) — updated as the picture clarifies:
Balanced (平和)
Qi deficiency (氣虛)
Yang deficiency (陽虛)
Yin deficiency (陰虛)
Phlegm-damp (痰濕)
Damp-heat (濕熱)
Blood stasis (血瘀)
Qi stagnation (氣鬱)
Special / allergic (特稟)
Constitution notes — tongue, pulse, cold/heat tendencies, and how the picture has shifted over time:

Chronic Conditions & Western History
Ongoing conditions, past diagnoses, and significant surgeries — with dates where known:
Family medical history relevant to care:

Allergies & Sensitivities
Drug allergies:
Herb sensitivities or past adverse reactions to TCM formulas:
Food, environmental, or other sensitivities:

Current Medications & Supplements
Prescription and over-the-counter medications, herbal formulas, and supplements — name, dose, and reason. Keep this current so we can watch for herb–drug interactions:

Safety Flags
Check any that currently apply — these change what treatment is safe:
Pregnant or trying to conceive
Currently breastfeeding
Has a pacemaker or other implanted electrical device
Taking blood thinners / anticoagulants
Bleeding disorder or bruises easily
Notes on any flag above (dates, details, changes):

Pattern Diagnosis & Treatment Course Log
A cumulative summary maintained by the practitioner — working pattern differentiation (辨證), principal treatment strategies, formulas and point prescriptions used, and how the patient has responded across each course of care. Newest entries at the top.

Running Notes
Add dated entries as things change — new medication, a pregnancy, a life event, a reaction to a formula, a shift in constitution. Newest at the top.

Keep this record current — it is the health picture we treat you from at every visit.
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Templates in this pack

The TCM Clinic pack includes 7 ready-to-use templates. Each one is a structured, fully editable form you can share with clients to collect information, documents, and signatures in one place.

Frequently asked questions

What's included in the TCM Clinic templates?
The TCM Clinic pack contains 7 templates: Patient Health & Constitution Record, TCM Initial Intake & Constitutional Assessment, Diagnosis & Treatment Plan, Treatment Session Record, Herbal Prescription Record, Course Completion & Follow-Up, Clinic Services & Treatment Guide. Each is ready to use and fully editable.
Can I customize these templates?
Yes. Every Pocper template is fully editable — add or remove fields, change the wording, and adapt each form to your workflow before sharing it with clients.
How do I use the TCM Clinic templates?
Import the pack into your Pocper workspace, open a template, tailor it to your needs, then share a link so clients can fill it out and upload documents in real time.