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
Get started with PocperA summary at the end of a TCM course — comparing baseline and current status, reviewing pattern resolution, and laying out a discharge or maintenance plan.
Patient name:
Course period (e.g. Mar 2025 – May 2025):
Total sessions completed:
Formulas used during the course:
Completion date:
Chief complaint at baseline (0 = none, 10 = worst):
Chief complaint right now (0 = none, 10 = worst):
Rate sleep, digestion, energy, and mood from 1 (poor) to 5 (excellent), at baseline and now:
Sleep — baseline: current:
Digestion — baseline: current:
Energy — baseline: current:
Mood — baseline: current:
Functional impact — baseline (work / family / daily life):
Functional impact — now:
Initial pattern:
Current pattern:
Pattern fully resolved
Significantly improved
Stable / no significant change
Mixed — some aspects better, others not
Tongue update:
Pulse update:
Adherence rating (1 = poor, 5 = excellent):
What worked well in the lifestyle plan?
What was hard to maintain?
Any side effects experienced during the course:
Long-term use — liver / renal function tests obtained
LFT (ALT/AST) values, if checked:
RFT (Cr/eGFR) values, if checked:
Notable herb reactions or interactions to record for the chart:
Discharge from active care
Monthly maintenance sessions
Seasonal tune-up (4× per year)
Refer to specialist for further evaluation
Specific recommendations for the next phase:
Western specialist (name / specialty):
Dietary counselling resource:
Mind-body therapy (qi gong / tai chi / meditation / counselling):
Overall rating (1 = poor, 5 = excellent):
Testimonial — what the patient would like to share about the experience:
Patient grants permission to use this testimonial and a photo (if provided) in clinic materials
Clinical observations, formula adjustments that worked best, lessons learned for similar cases:
Course is concluded and home plan understood
Thank you for completing this course. May your qi flow smoothly and your body, mind, and spirit stay in harmony.
The Course Completion & Follow-Up template is a ready-to-use form from Pocper's TCM Clinic pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.