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.
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
2. / pinyin or Latin: — g
3. / pinyin or Latin: — g
4. / pinyin or Latin: — g
5. / pinyin or Latin: — g
6. / pinyin or Latin: — g
7. / pinyin or Latin: — g
8. / pinyin or Latin: — g
9. / pinyin or Latin: — g
10. / pinyin or Latin: — g
11. / pinyin or Latin: — g
12. / pinyin or Latin: — g
Modifications and rationale (additions, subtractions, dose adjustments):
Preparation instructions (e.g. soak 30 min, simmer 30 min in 600 ml water, divide into 2 doses):
Pickup schedule (e.g. weekly pickup, refill at session 4):
Foods to avoid during the course:
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.:
What to track at home (check all that apply):
Symptom diary template provided (URL / format):
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Take the herbs as directed. If anything feels unusual, contact the clinic before the next dose.