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 PocperThis document records the four examinations — inspection, auscultation/olfaction, inquiry, and palpation — synthesises a TCM pattern differentiation, and lays out the treatment principle, modalities, and course plan for the patient.
Patient name:
Visit date:
Practitioner:
Visit type: [New consultation / Follow-up visit]
Complexion:
[Practitioner notes complexion — e.g. Pale / Yellow / Red / Dark with TCM interpretation]
Physical build:
[Practitioner notes build — Thin/frail / Robust / Overweight (damp build)]
Demeanour and spirit:
Eyes / lips / skin observations:
Voice:
[Practitioner notes voice — Weak/low (deficiency) or Loud/forceful (excess)]
Cough characteristic:
[Practitioner notes cough — Dry / Productive / Wheezing — and any breath or body odour observations]
Notes:
Refer back to the intake form. Record updates, new symptoms, or clarifications gathered today:
Qualities to consider: floating / sinking / slippery / wiry / thin / rapid / slow / weak / forceful.
Position | Left Hand | Right Hand |
Cun | Heart: | Lung: |
Guan | Liver: | Spleen: |
Chi | Kidney yin: | Kidney yang: |
Overall pulse pattern interpretation:
Body colour:
[Practitioner notes — Pale / Pink / Red / Purple / Dark]
Body shape:
[Practitioner notes — Swollen / Thin / Tooth-marked / Cracked]
Coating colour:
[Practitioner notes — White / Yellow / Grey / Black]
Coating thickness:
[Practitioner notes — Thin / Thick / Peeled or patchy]
Coating texture:
[Practitioner notes — Dry / Moist / Greasy or sticky]
Tongue notes (location of features, sublingual veins, etc.):
Primary pattern (e.g. "Liver Qi stagnation with Spleen deficiency"):
Secondary pattern, if any:
Pathogenic factors:
[Practitioner notes applicable factors — Wind / Cold / Heat / Dampness / Dryness / Fire]
Root cause analysis and the relationship between root and branch:
e.g. "Soothe the Liver, strengthen the Spleen, resolve dampness".
[Practitioner selects modalities — Acupuncture / Cupping / Tuina / Gua sha / Moxibustion / Electroacupuncture / Herbal formula / External application (poultice or wash) / Dietary therapy]
List points with rationale (e.g. LV3 Taichong — soothe Liver, move Qi):
Base formula name (e.g. Jiawei Xiaoyao San (modified)):
Modifications and rationale:
Sessions per week: [1 / 2 / 3 sessions per week — practitioner selects]
Total sessions planned:
Expected timeframe:
Review checkpoint (after how many sessions):
Foods to favour / avoid, sleep guidance, exercise (e.g. tai chi, qi gong, walking), and emotional self-care:
Realistic goals at the review checkpoint and at course completion:
e.g. mild bruising from cupping, transient soreness after needling, possible herb side effects, healing crisis.
Practitioner name:
Signature date:
Patient has reviewed the plan and agrees to proceed
This plan will be re-evaluated at the review checkpoint and adjusted to the body’s response.
Authorized representative — printed name:
Signed date:
Signer — printed name:
Signed date:
The Diagnosis & Treatment Plan 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.