Traditional Chinese Medicine Initial Evaluation Note (Four Examinations)

Date/Time: [Encounter start date and time]
Location: [in-person / telehealth] (If telehealth, note any exam limitations such as pulse not assessed.)
Patient: [Full name], [DOB]
Practitioner: [Name], [Credentials], [License number and jurisdiction]
Referral Source: [Referring clinician/organization and reason for referral] (Include only if applicable.)
Interpreter: [Language and modality] (Include only if used.)
Consent Status: [General treatment consent and specific modality consents obtained: needling, electroacupuncture, cupping, gua sha, moxibustion, herbal therapy, tongue photos as applicable]

Subjective

Chief Complaint & Goals

Chief Complaint: "[Chief complaint in patient's own words]"

Patient-stated goals: [Goal 1]; [Goal 2]; [Goal 3] (List 1–3 goals; note priority if multiple complaints.)

History of Present Illness

(Write in paragraph form for each primary complaint. Include onset/precipitating events; location/radiation; quality and severity with 0–10 scale where relevant; frequency/timing patterns; aggravating/relieving factors; associated symptoms including safety-relevant associations; prior evaluation and treatment with response; functional impact on work, ADLs, sleep, mood; patient treatment preferences. Label negatives as denied, items not assessed as not asked, and uncertainty as unknown.)

Problem 1:

[Narrative HPI for Problem 1]

Problem 2:

(Include only if applicable.) [Narrative HPI for Problem 2]

Problem 3:

(Include only if applicable.) [Narrative HPI for Problem 3]

Medical and Social History

• Past medical/surgical history: [Pertinent conditions, surgeries, major injuries]
• Current medications and supplements: [List with doses if provided] (Flag anticoagulants, immunosuppressants, glycemic agents, psychoactive medications.)
• Allergies/adverse reactions: [Medications, foods, latex, prior reactions to acupuncture or adjunct therapies]
• Family history: [Pertinent positives/negatives]
• Social history: [Occupation], [Stressors], [Sleep schedule], [Tobacco/alcohol/substances], [Diet], [Exercise]
• Reproductive history: [Pregnancy status], [LMP], [Cycle details], [Lactation] (Include only if relevant to complaint or treatment planning.)
• Previous TCM history: [Prior patterns diagnosed], [Treatments used], [Response]

Safety Screening

Red flag screening: [No red flags identified / Red flags present] (If none, list key negatives screened relevant to chief complaint. If present, specify findings, action taken, referral status. If patient declines referral, document capacity assessment, counseling provided, and return precautions.)

• Cardiopulmonary: [Chest pain, syncope, severe dyspnea — denied / present / not asked]
• Neurologic: [New focal weakness, saddle anesthesia, bowel/bladder changes — denied / present / not asked]
• Systemic: [Fever, unexplained weight loss, night sweats — denied / present / not asked]
• Infection: [Spreading redness, systemic toxicity — denied / present / not asked]
• Hemorrhage risk: [Anticoagulant/bleeding disorder status and plan]
• Pregnancy emergencies: [Status/details] (Include only if relevant.)
• Mental health safety: [Suicidality, homicidality screening and actions taken] (Include only if relevant.)

Modality contraindications/precautions: [Bleeding risk], [Active skin infection], [Implanted electrical device], [Metal allergy], [History of needle syncope], [Immunosuppression], [Pregnancy-related point precautions], [Dermatologic fragility], [Heat sensitivity/poor sensation] (For any positive finding, document mitigation plan.)

Review of Systems / TCM Inquiry

(Document clinically meaningful positives and negatives relevant to pattern differentiation.)

• Temperature sensations: [Hot/cold preference, aversion to wind]
• Sweating: [Spontaneous, night sweats, exertional]
• Head/face/senses: [Headache, dizziness, vision, hearing, throat]
• Thirst/fluids/urination: [Thirst level, preferred drink temperature, dry mouth, urinary findings]
• Appetite/digestion: [Appetite, taste, nausea, reflux, bloating, stool quality]
• Sleep: [Onset, maintenance, dreams, restfulness]
• Pain characteristics: [Quality, fixed vs wandering, response to temperature/pressure]
• Chest/respiration: [Cough, wheeze, shortness of breath, phlegm]
• Emotional state: [Irritability, anxiety, rumination, grief]
• Menstruation: [Cycle regularity, flow, color, clots, pain, PMS] (Include only if applicable.)
• Energy/fatigue: [Patterns and triggers]

Objective

Inspection (望)

• General appearance: [Posture, movement, build, complexion, eyes/shen, demeanor, relevant skin findings]
• Tongue: [Body color], [Shape: swollen/thin, teeth marks, cracks], [Moisture], [Coating: color, thickness, distribution, texture], [Sublingual veins] (Note factors affecting validity such as recent food/drink, scraping, lighting. If not performed, state reason and do not infer findings.)

Listening and Smelling (闻)

(Include only if assessed and clinically relevant.) [Voice quality/volume], [Breathing/cough characteristics], [Notable odors]

Palpation (切)

• Pulse: [Rate], [Rhythm], [Depth], [Strength], [Width], [Quality descriptors], [Left/right differences], [Cun/Guan/Chi details if used] (Note any limitations. If not assessed, state reason and do not infer.)
• Additional palpation: [Channel/ashi tenderness], [Temperature differences], [Abdominal findings], [Relevant musculoskeletal or neurological exam within scope] (Include only findings assessed.)

Vitals and Examination

• Vital signs: [BP], [HR], [RR], [Temp], [SpO2] (Include when indicated by chief complaint.)
• Focused physical exam: [Pertinent findings relevant to complaint]
• Diagnostics reviewed: [Labs/imaging reviewed and source] (Include only if actually reviewed.)

Assessment

Problem List and Pattern Differentiation

(List problems in order of clinical priority. If any component of Four Examinations was not assessed, label pattern differentiation as provisional.)

Problem 1

• Problem: [Biomedical working diagnosis or symptom-based description]
• TCM Pattern(s): [Primary pattern]; [Secondary pattern(s) if clinically meaningful]
• Pattern Rationale: [Key inquiry, tongue, pulse, palpation findings supporting the pattern(s)] (Note if provisional and what data is missing.)
• Differential Patterns: [Alternative patterns with supporting/contradicting findings and plan to clarify] (Include only if diagnostic uncertainty exists.)

Problem 2

(Include only if applicable.)

• Problem: [Description]
• TCM Pattern(s): [Pattern(s)]
• Pattern Rationale: [Findings supporting pattern(s)]
• Differential Patterns: [List] (Include only if applicable.)

Safety Synthesis

[No red flags identified; appropriate for outpatient TCM care / Red flags identified: (findings and action taken including referrals or treatment deferrals)] [Modality modifications: (e.g., no electroacupuncture due to implanted device, avoid heat therapy due to neuropathy, pregnancy-related point modifications)]

Baseline Outcome Measures

• Primary symptom measure: [Measure and scale] — Baseline: [Value]; Target: [Goal]; Reassessment: [Interval]
• Functional measure: [Specific activity metric] — Baseline: [Value]; Target: [Goal]; Reassessment: [Interval]
• Patient-priority outcome: [What matters most to patient] — Baseline: [Value]; Target: [Goal]; Reassessment: [Interval]

(If outcomes not collected, document reason and plan for introduction.)

Plan

Treatment Principle

[TCM treatment principles using action-oriented verbs: tonify, clear, warm, transform, move, harmonize, calm shen, raise, descend] (Prioritize 1–3 principles tied to each problem.)

Treatment Today

(Include only if same-day treatment performed.)

• Modality: [Manual acupuncture / Electroacupuncture / Auricular / Scalp / Other]
• Patient position: [Supine / Prone / Lateral / Seated]
• Points used: [Points with laterality, e.g., LI4 bilateral, ST36 R]
• Needle count and retention: [Count], [Minutes]
• Technique: [Tonify / Reduce / Even], [Stimulation method], [Electro settings if used]
• Adjunct therapies: [Moxa type/location], [Cupping type/duration], [Gua sha area], [Other]
• Patient response: [Tolerance, adverse events if any, management provided]
• Post-treatment instructions: [Guidance and return precautions provided]

Course of Treatment

• Frequency/duration: [e.g., 1–2 times weekly for 4–6 weeks]
• Reassessment point: [e.g., re-evaluate after 6 visits]
• Criteria to continue/modify/discontinue: [Tied to outcome measures]
• Phases: [Stabilize/Improve → Consolidate → Maintenance] (Include if applicable.)

Goals

• Problem 1: Symptom goal: [Target]; Function goal: [Target]; Patient-priority goal: [Target] — Timeframe: [e.g., 4 weeks]
• Problem 2: [Goals and timeframe] (Include only if applicable.)

Patient Education

• Lifestyle recommendations: [Sleep hygiene, dietary guidance, stress management, movement]
• Home therapies: [Acupressure, heat/ice, breathing exercises, other]
• Safety guidance: [Symptoms requiring urgent care and return precautions]

Referrals and Follow-up

• Referrals: [PCP / Specialist / Urgent care / Other with reason and urgency] (Include only if applicable.)
• Records requested: [Source and type] (Include only if applicable.)
• Follow-up: [Next visit timing] — To assess: [Outcome measures, pattern changes, treatment response]

Signature

Practitioner Signature: [Name], [Credentials] — [Date/Time of completion]
Supervisor Co-signature: [Name, Credentials] (Include only if applicable.)