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 per-visit record covering modalities applied, points needled, patient response, and the plan for next time. Keeps the course log consistent and traceable.
Patient name:
Session number:
Session date:
Practitioner:
Modality applied today (check all that apply):
Acupuncture
Cupping
Tuina
Gua sha
Moxibustion
Electroacupuncture
Herbal pickup only (no in-clinic procedure)
Current chief complaint and changes since the last visit:
Pulse update (one line):
Tongue update (one line):
Mood / energy snapshot:
For each row enter: point name + side (L/R/Bil) + technique (tonify / reduce / even / electric) + retention (min).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
De qi sensation, electrical stimulation parameters, and other notes:
Cupping — sites:
Cupping — duration (min):
Tuina — region(s) worked:
Tuina — duration (min):
Gua sha — region(s):
Gua sha — intensity (light / moderate / strong):
Moxibustion — sites:
Moxibustion — type:
Direct
Indirect
Stick
Box
Sensations reported (check all that apply):
Warmth
Heaviness
Tingling
Soreness / aching
Radiating sensation along channel
Sleep state during retention:
Relaxed but awake
Dozed off / fell asleep
Restless / fidgety
Immediate response after treatment:
No adverse events observed
Details (if any) — bruising, dizziness, fainting, allergic reaction, etc.:
Formula dispensed:
Number of packs:
Preparation and dosing instructions reviewed with patient
Precautions and possible side effects reviewed with patient
Next session date:
Recommended self-care between sessions (qi gong, stretches, warm baths, sleep, etc.):
Foods or herbs to avoid until next visit:
Practitioner name:
Session record reviewed and confirmed accurate
See you at the next visit. Rest well, drink warm water, and avoid cold or heavy meals for the rest of the day.
Authorized representative — printed name:
Signed date:
Signer — printed name:
Signed date:
The Treatment Session 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.