Patient Progress Note
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1Patient Progress Note
Please fill out form at each visit and return to the front desk assistant when finished. Thank you for your assistance.
Patient Name ___________________________________________ Date_____________________
Please mark the area
where there is pain.
X=Sharp Pain
O=Dull Pain
Please mark the level of intensity of your symptoms using the following scale.
(0 equals no symptom at all, 100 equals maximum possible intensity of the symptom.)
Symptom___________________________________
0 10 20 30 40 50 60 70 80 90 100
Symptom___________________________________
0 10 20 30 40 50 60 70 80 90 100
Symptom___________________________________
0 10 20 30 40 50 60 70 80 90 100
Symptom___________________________________
0 10 20 30 40 50 60 70 80 90 100
Please rate by circling your overall state of wellness since your last treatment
Significantly Improved
Improved
Unchanged
Worsened
Significantly Worsened
(Office Use Only)
PATIENT’S NOTES
Units:
Set: 1
2
3
4
What has changed?
Needle #
LV
________________________________________________________
GB
________________________________________________________
HT
SI
________________________________________________________
PC
SJ
________________________________________________________
SP
ST
Do you have any health concerns that you would like to
LU
communicate to the doctor other than those for which you are
currently being treated for? If yes, please describe:
LI
KD
________________________________________________________
UB
REN
________________________________________________________
DU
EXTRA
________________________________________________________
ASHI
SCALP
________________________________________________________
EAR
________________________________________________________
MOXA/TDP
TUINA/CUP
o
:________________________
(Check here if documenting any physician notes on reverse) Physician’s Signature
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Parent category: Medical