Herbal Prescription Record

A formal record of the herbal formula prescribed today — composition with sovereign / minister / assistant / envoy roles, preparation method, dosing, precautions, and follow-up.

Prescription Header

Patient name:

Prescription date:

Practitioner:

Formula name:

Formula type:

Classical formula

Modified classical formula

Individualised formula

External use

Patient Pattern Recap

Pattern diagnosis:

Treatment principle this formula is built around:

Herbal Composition

For each row enter herb name, pinyin / Latin name, dosage in grams, and check the role: Sovereign / Minister / Assistant / Envoy.

1. / pinyin or Latin: — g

JūnChénZuǒShǐ

2. / pinyin or Latin: — g

JūnChénZuǒShǐ

3. / pinyin or Latin: — g

JūnChénZuǒShǐ

4. / pinyin or Latin: — g

JūnChénZuǒShǐ

5. / pinyin or Latin: — g

JūnChénZuǒShǐ

6. / pinyin or Latin: — g

JūnChénZuǒShǐ

7. / pinyin or Latin: — g

JūnChénZuǒShǐ

8. / pinyin or Latin: — g

JūnChénZuǒShǐ

9. / pinyin or Latin: — g

JūnChénZuǒShǐ

10. / pinyin or Latin: — g

JūnChénZuǒShǐ

11. / pinyin or Latin: — g

JūnChénZuǒShǐ

12. / pinyin or Latin: — g

JūnChénZuǒShǐ

Modifications and rationale (additions, subtractions, dose adjustments):

Preparation Method

Decoction (water decoction)

Granules

Pills

Tincture

External poultice

External wash

Preparation instructions (e.g. soak 30 min, simmer 30 min in 600 ml water, divide into 2 doses):

Dosing Schedule

Frequency:

1× per day

2× per day (morning and evening)

3× per day

Timing:

Before meals

After meals

On an empty stomach

Before sleep

Take with warm water

Course Length

Days of treatment:

Packs dispensed:

Pickup schedule (e.g. weekly pickup, refill at session 4):

Precautions

Foods to avoid during the course:

Spicy / pungent food

Cold drinks and ice

Raw food (sashimi, salads)

Dairy

Specific allergens (note below)

Do not combine with the following Western medications / supplements:

Pregnancy / lactation considerations:

Possible Side Effects

Minor effects to expect (e.g. transient digestive changes, mild bowel changes):

What to do if a severe reaction occurs (rash, vomiting, swelling):

Storage

Keep dry, refrigerate after preparing decoction, etc.:

Follow-Up

Next visit date:

What to track at home (check all that apply):

Sleep

Digestion

Mood

Pain

Symptom diary template provided (URL / format):

Pricing

Price per pack:

Total amount:

Insurance applicable

Payment received

Sign-Off

Practitioner signature:

Patient acknowledges receipt of formula and understands all instructions and precautions

Take the herbs as directed. If anything feels unusual, contact the clinic before the next dose.