Diagnosis & Treatment Plan
This 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.
Visit type: [New consultation / Follow-up visit]
[Practitioner notes complexion — e.g. Pale / Yellow / Red / Dark with TCM interpretation]
[Practitioner notes build — Thin/frail / Robust / Overweight (damp build)]
○ Overweight / damp constitution
[Practitioner writes this when drafting]
Eyes / lips / skin observations:
Eyes / lips / skin observations:
[Practitioner notes voice — Weak/low (deficiency) or Loud/forceful (excess)]
[Practitioner notes cough — Dry / Productive / Wheezing — and any breath or body odour observations]
○ Productive / with phlegm
[Practitioner writes this when drafting]
Refer back to the intake form. Record updates, new symptoms, or clarifications gathered today:
[Practitioner writes this when drafting]
Qualities to consider: floating / sinking / slippery / wiry / thin / rapid / slow / weak / forceful.
Overall pulse pattern interpretation:
[Practitioner writes this when drafting]
[Practitioner notes — Pale / Pink / Red / Purple / Dark]
[Practitioner notes — Swollen / Thin / Tooth-marked / Cracked]
[Practitioner notes — White / Yellow / Grey / Black]
[Practitioner notes — Thin / Thick / Peeled or patchy]
[Practitioner notes — Dry / Moist / Greasy or sticky]
Tongue notes (location of features, sublingual veins, etc.):
Tongue notes (location of findings, sublingual veins, etc.):
[Practitioner writes this when drafting]
Primary pattern (e.g. "Liver Qi stagnation with Spleen deficiency"):
[Practitioner writes this when drafting]
Secondary pattern, if any:
[Practitioner writes this when drafting]
Pathogenic factors — check all that apply:
Secondary pattern, if any:
[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 writes this when drafting]
[Practitioner selects modalities — Acupuncture / Cupping / Tuina / Gua sha / Moxibustion / Electroacupuncture / Herbal formula / External application (poultice or wash) / Dietary therapy]
○ External application (poultice / wash)
Suggested Acupuncture Points
List points with rationale (e.g. LV3 Taichong — soothe Liver, move Qi):
[Practitioner writes this when drafting]
Base formula name (e.g. Jiawei Xiaoyao San (modified)):
Modifications and rationale:
[Practitioner writes this when drafting]
Sessions per week: [1 / 2 / 3 sessions per week — practitioner selects]
Review checkpoint (after how many sessions):
Lifestyle & Dietary Advice
Foods to favour / avoid, sleep guidance, exercise (e.g. tai chi, qi gong, walking), and emotional self-care:
[Practitioner writes this when drafting]
Realistic goals at the review checkpoint and at course completion:
[Practitioner writes this when drafting]
Possible Reactions / Caution
e.g. mild bruising from cupping, transient soreness after needling, possible herb side effects, healing crisis.
[Practitioner writes this when drafting]
This plan will be re-evaluated at the review checkpoint and adjusted to the body’s response.
Authorized representative — printed name:
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