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Patient 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 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
Needle #
LV
GB
HT
SI
PC
SJ
SP
ST
LU
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:________________________
Please mark the area
where there is pain.
X=Sharp Pain
O=Dull Pain
What has changed?
________________________________________________________
________________________________________________________
________________________________________________________
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Do you have any health concerns that you would like to
communicate to the doctor other than those for which you are
currently being treated for? If yes, please describe:
________________________________________________________
________________________________________________________
________________________________________________________
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