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 formal record of the herbal formula prescribed today — composition with sovereign / minister / assistant / envoy roles, preparation method, dosing, precautions, and follow-up.
Patient name:
Prescription date:
Practitioner:
Formula name:
Formula type:
Classical formula
Modified classical formula
Individualised formula
External use
Pattern diagnosis:
Treatment principle this formula is built around:
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):
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):
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
Days of treatment:
Packs dispensed:
Pickup schedule (e.g. weekly pickup, refill at session 4):
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:
Minor effects to expect (e.g. transient digestive changes, mild bowel changes):
What to do if a severe reaction occurs (rash, vomiting, swelling):
Keep dry, refrigerate after preparing decoction, etc.:
Next visit date:
What to track at home (check all that apply):
Sleep
Digestion
Mood
Pain
Symptom diary template provided (URL / format):
Price per pack:
Total amount:
Insurance applicable
Payment received
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.
The Herbal Prescription Record 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.