EL – Acupuncture NEW

DOS:
[date name="variable_1"]
Patient name:
[textarea cols=40 rows=1]
DOB:
[date name="variable_2"]

[checkbox name="patient" value="Online  intake forms reviewed, information validated and clarified|Paper intake forms reviewed, information validated and clarified|consent obtained||significant other/family member present during visit|chaperon/assistant present during visit||complete history/physical exam limited due to language barrier|complete history/physical exam limited due to pain|complete history/physical exam limited due to knowledge deficit|complete history/physical exam limited due to affect|complete history/physical exam limited due to hearing impairment|complete history/physical exam limited due to poor effort||interpretation provided by family member/SO|interpretation provided by language line|"][textarea cols=20 rows=1].

SUBJECTIVE
Head & Face:
[checkbox name="head" value="headache|facial pain|occipital pain|"][textarea cols=20 rows=1].

Axial/CS:
[checkbox name="cs" value="no symptoms suggesting CS involvement||occipital tightness/burning|neck pain/stiffness|pain/spasm in trapezius area||w/o radiation|w/ radiation to forehead|w/ radiation caudally|w/ radiation to right|w/ radiation to left|w/ radiation to deltoid area|w/ radiation to forearm/hand|burning in UE|"][textarea cols=20 rows=1].

Axial/TS:
[checkbox name="ts" value="no symptoms suggesting TS involvement||pain w/ deep breath|interscapular pain||w/o radiation|w/ radiation to right scapular area|w/ radiation to left scapular area||w/ radiation to right upper arm|w/ radiation to left upper arm|w/ radiation caudally|w/ radiation to chest wall|"][textarea cols=20 rows=1].

Axial/LS:
[checkbox name="ls" value="no symptoms suggesting LS involvement||pain/spasm in lumbar area||w/o radiation|w/ radiation to left buttock|w/ radiation to right buttock||w/ radiation to left thigh|w/ radiation to right thigh||w/ radiation to below knee on left|w/ radiation to below knee on right||burning in RLE|burning in LLE||R leg giving out|L leg giving out|"][textarea cols=20 rows=1].

Extremities:
[checkbox name="ex" value="no concerns|pain/swelling in|"][textarea cols=20 rows=1].

Other symptoms:
[textarea cols=70 rows=5].

Functional Assessment:
[checkbox name=”funct2" value="symptoms interfere with ADLs|symptoms interfere with sleep|symptoms interfere with recreation|symptoms interfere with life enjoyment|symptoms cause depression|"][textarea cols=40 rows=1].

CC 1 – PROBLEM TO ADDRESS TODAY
CC/Dx:
[textarea cols=40 rows=2].

Stated cause:
[checkbox name="cause1" value="accident/trauma/fall/injury|sudden onset during normal activity|gradual onset|unknown|"][textarea cols=20 rows=1].

Previous Evaluations and Treatments:
[checkbox name="prev1" value="imaging||medication therapy|physical therapy, chiropractic, massage, acupuncture|therapeutic injections/nerve blocks|surgery||improved with previous management|unchanged with previous management||medication partially helps|medication doesn't help||acupuncture helped before|"][textarea cols=20 rows=1].

- Timing:
[checkbox name="timing1" value="long-standing problem|symptoms stable for years|symptoms fluctuate|recent re-injury/exacerbation/falls|"][textarea cols=20 rows=1].
- Frequency:
[checkbox name="freq1" value="occasional|frequent|constant|"][textarea cols=20 rows=1].
= Intensity:
best [text]/10, worst [text]/10.
- Laterality:
[checkbox name="lat1" value="bilateral|on left|on right|moves from right to left||worse on left|worse on right|"][textarea cols=20 rows=1].
- Quality:
[checkbox name="qual1" value="sharp|dull|tingling|numbness|shooting|"][textarea cols=20 rows=1].
- Radiation:
[checkbox name="rad1" value="none||proximally|distally||caudally|rostrally|"][textarea cols=20 rows=1].
- Worse with/at:
[checkbox name=”worse1" value="movement|flexion|extension|twisting||rest|sleep||sitting|standing|walking||straining|weather changes||daytime|nighttime||"][textarea cols=40 rows=1].
- Better with/during:
[checkbox name=”better1" value="movement|flexion|extension||rest|sleep|sitting|walking||heat application|cold application||daytime|nighttime|"][textarea cols=40 rows=1].

[checkbox memo="Problem_2" name="prob" value=""][conditional field="prob" condition="(prob).is('')"]
CC 2 – PROBLEM TO ADDRESS TODAY

CC/Dx:
[checkbox name="cc2" value="N/A"][textarea cols=40 rows=2].

Stated cause:
[checkbox name="cause2" value="accident/trauma/fall/injury|sudden onset during normal activity|gradual onset|unknown|"][textarea cols=20 rows=1].

Previous Evaluations and Treatments:
[checkbox name="prev2" value="imaging||medication therapy|physical therapy, chiropractic, massage, acupuncture|therapeutic injections/nerve blocks|surgery||improved with previous management|unchanged with previous management||medication partially helps|medication doesn't help||acupuncture helped before|"][textarea cols=20 rows=1].

- Timing:
[checkbox name="timing2" value="long-standing problem|symptoms stable for years|symptoms fluctuate|recent re-injury/exacerbation/falls|"][textarea cols=20 rows=1].
- Frequency:
[checkbox name="freq2" value="occasional|frequent|constant|"][textarea cols=20 rows=1].
- Intensity:
best [text]/10, worst [text]/10.
- Laterality:
[checkbox name="lat2" value="bilateral|on left|on right|moves from right to left||worse on left|worse on right|"][textarea cols=20 rows=1].
- Quality:
[checkbox name="qual2" value="sharp|dull|tingling|numbness|shooting|"][textarea cols=20 rows=1].
- Radiation:
[checkbox name="rad2" value="none||proximally|distally||caudally|rostrally|"][textarea cols=20 rows=1].
- Worse with/at:
[checkbox name=”worse2" value="movement|flexion|extension|twisting||rest|sleep||sitting|standing|walking||straining|weather changes||daytime|nighttime||"][textarea cols=40 rows=1].
- Better with/during:
[checkbox name=”better2" value="movement|flexion|extension||rest|sleep|sitting|walking||heat application|cold application||daytime|nighttime|"][textarea cols=40 rows=1].[/conditional]

ROS
See attached Initial Health Status form for additional history, review of systems, medical history, social history, surgical history, diagnostic and laboratory studies.

PMH
See attached Initial Health Status form for additional history, review of systems, medical history, social history, surgical history, diagnostic and laboratory studies.


OBJECTIVE
VS:
[textarea cols=30 rows=1].

Tongue Body:
[checkbox name="tongue" value="red|purple|white|dusky||flabby|ridig|trembling||wide/swollen|narrow|cracked|scalloped||"][textarea cols=20 rows=1].    
Tongue coating:
[checkbox name="coat" value="thick|thin||white|yellow||greasy|wet|dry|"][textarea cols=20 rows=1].    
Pulse:
[checkbox name="pulse" value="forceful|weak|moderate||big|thin||deep|superficial||hard|soft||fast|slow|"] [textarea cols=20 rows=1].

General:
[checkbox name="gen" value="good energy|smiling||guarding|moving slowly||using walker|using cane|"][textarea cols=20 rows=1].

Posture & Gait:
[checkbox name="post" value="straight|guarding|stooped||ambulates w/o limp|limping|ataxic gait|wide gait|antalgic gait|shuffling gait|"][textarea cols=20 rows=1].

Psychomotor Activity:
[checkbox name="act" value="no involuntary movements||grimacing, furrowing eyebrows||bradykinetic|deliberate|fast|fidgety|restless||tremor|tics|"][textarea cols=20 rows=1].

Behavior/Mental Status:
[checkbox name="beh" value="cooperative|pleasant||guarded|withdrawn|hypoverbal|forgetful||anxious|labile|sighing|crying||irritable|frustrated|argumentative|forceful|hypervigilant|euphoric|"][textarea cols=20 rows=1].

Neuro:
[checkbox name="neur" value="balance & coordination grossly intact|detailed neuro exam deferred|"][textarea cols=20 rows=1].

Face:
[checkbox name="face" value="normal exam|cranial nerves grossly intact|very sensitive to light touch|asymmetry|rash|"][textarea cols=20 rows=1].

Cervical Spine:
[checkbox name="cerv" value="normal exam|painless ROM|symmetric with free painless ROM||(sub)occipital tenderness|paraspinal tenderness|paracervical muscle spasm|limited range of motion||trigger points in trapezius|trigger points in levator scapulae||abrasion|bruise|swelling|color changes|old surgical scar|rash||hand grips intact|no drift observed|UE strong w/o atrophy|sensory grossly intact to touch||reflexes not tested|"][textarea cols=20 rows=1].

Thoracic Spine & Chest:
[checkbox name="th" value="normal exam|normal WOB|chest wall non-tender||paraspinal tenderness|trigger points in parascapular area|"][textarea cols=20 rows=1].

Lumbar Spine:
[checkbox name="lmb" value="normal exam|painless ROM|skin normal color and temperature||decreased ROM|QL tenderness|paraspinal tenderness||trigger points in gluteal musculature|palpable muscle spasm||swelling|bruise|color changes|old surgical scar|rash||heel/toe walk intact|sensory grossly intact to touch|seated SLR negative bil|seated SLR positive on R|seated SLR positive on L||reflexes not tested|"][textarea cols=20 rows=1].

Upper Extremity:
[checkbox name="ue" value="normal inspection|"][textarea cols=40 rows=2].

Lower Extremity:
[checkbox name="le" value="normal inspection|| pedal skin warm with good & equal pulses|| ankle edema|varicosities|stasis discoloration|"][textarea cols=40 rows=2].

Abdominal Palpation:
[checkbox name="palp" value="no resistance felt throughout||resistance felt in epigastric area|resistance felt in RUQ|resistance felt in LUQ||resistance felt in periumbilical area|resistance felt in RLQ|resistance felt in LLQ||resistance felt throughout||patient declined|deferred|"][textarea cols=20 rows=1].

ASSESSMENT
Dx:
[textarea cols=40 rows=1].

TCM PATTERN:
[checkbox name="tcm" value="Deficiency|Excess||Qi stagnation|Qi deficiency|Xue stagnation|Xue deficiency|Yin deficiency|Yang deficiency||Dampness|Heat|Cold|Dryness|Wind|"][textarea cols=20 rows=1].

THERAPEUTIC GOALS
Provide symptomatic pain relief: pain level below [text].
Relieve muscle spasm in [text].
Increase blood circulation in [text].
Improve range of motion in in [text].
Promote general relaxation response.
Improve sleep.
Increase mobility.
[textarea cols=40 rows=1]
INTERVENTIONS
Active Rehabilitation:
Emphasize patient responsibility, encourage early return to activity, promote therapeutic exercise/stretching, advise on life-style modification.
Cognitive restructuring:
How to live with pain and reasonable expectations.

Primary Modality:
Acupuncture.
Adjunctive Therapies:
[checkbox name="adj" value="infrared therapy|therapeutic ultrasound|low level laser|acupoint injection|"][textarea cols=20 rows=1].
Projected/Requested Services:
Dates of service: [date name="variable_3"] (today) through [date name="variable_4"] (6 weeks).
Visits: 6-8 treatments in total.
Frequency: once to twice per week, downgrade as symptoms improve.
Progress Towards Goals:
Re-evaluate every 3rd visit.
Positive patient response measured via functional gains such as positional tolerances, range-of-motion, strength, endurance, activities of daily living, cognition, and psychological behavior.
If no improvement, reconsider original diagnosis and/or modify therapeutic regimen.
Cease acupuncture If poor response or exacerbation of symptoms.
Consider:
Refer to specialty for detailed ortho / neuro examination.
Refer to PCP to address chronic health issues.
Refer to mental health to learn stress management.
Rehab Potential:
[checkbox name="rehab" value="good rehabilitation potential d/t||younger age|current health status|high motivation|cognitive functioning|prior level of function||guarded rehabilitation potential d/t||advanced age|smoking|multiple comorbidities|high BMI|DM|steroid use|poor insight|"][textarea cols=20 rows=1].

TREATMENT
Consent:
Procedure, R/B/A, potential SE, aftercare explained. Patient verbalized understanding & agreed w POC.
Treatment points localized based on TCM pattern, direct tenderness, local twitch response, proximity to problem area, spinal segment, and radiation patterns.
Primary Modality:
[checkbox name="modality" value="Acupuncture (dry needling) w/o electrostimulation|Acupuncture (dry needling) w/ electrostimulation"]

First Insertion:
Position:
[checkbox name="position" value="supine on table|prone on table|L side-lying on massage table|R side-lying on massage table||seated in massage chair face down|seated in massage chair face up|seated in office chair|seated on stool leaning against desktop massage system|"][textarea cols=20 rows=1].
Preparation:
Prior to needling, [checkbox name="prep" value="treatment area palpated|cupping applied to treatment area|infrared therapy applied to treatment area|"][textarea cols=20 rows=1].
Procedure:
Skin prepped w/ alcohol.
Inserted [text] needles [checkbox name="depth" value="superficially|subcutaneously|into myofacial layer|"]: [checkbox name="points" value="in occipital scalp|in suboccipital area|in trapezius muscle|in levator scapula|around scapula||along GV channel|along inner BL line|paraspinally|along outer BL line||in CS|in TS|in LS||in QL|in buttocks||around joint|"][textarea cols=30 rows=3].
De Qi/twitch response [checkbox name="deqi" value="obtained/observed|not sought"].    

Needles [checkbox name="retain" value="retained for 8 to 15 minutes|retained for several minutes|additionally stimulated throughout treatment"].  

Electrical stimulation [checkbox name="ea" value="applied|not applied"].    

Removed and counted intact [text] needles.

[checkbox memo="Insertion_2" name="insert" value=""][conditional field="insert" condition="(insert).is('')"]
Second Insertion:
Position:
[checkbox name="position" value="supine on table|prone on table|L side-lying on massage table|R side-lying on massage table||seated in massage chair face down|seated in massage chair face up|seated in office chair|seated on stool leaning against desktop massage system|"][textarea cols=20 rows=1].

Preparation:
Prior to needling, [checkbox name="prep" value="treatment area palpated|cupping applied to treatment area|infrared therapy applied to treatment area|"][textarea cols=20 rows=1].
Procedure:
Skin prepped w/ alcohol.
Body acupuncture: [text] needles [checkbox name="depth" value="superficially|subcutaneously|into myofacial layer|"] - [checkbox name="points" value="in occipital scalp|in suboccipital area|in trapezius muscle|in levator scapula|around scapula||along GV channel|along inner BL line|paraspinally|along outer BL line||in CS|in TS|in LS||in QL|in buttocks||around joint|"][textarea cols=30 rows=3].
De Qi/twitch response [checkbox name="deqi" value="obtained/observed|not sought"].
Ear acupuncture:
R ear: [text].
L ear: [text].
Needles [checkbox name="retain" value="retained for 8 to 15 minutes|retained for several minutes|additionally stimulated throughout treatment"].  
Electrical stimulation [checkbox name="ea" value="applied|not applied"].    

Removed and counted intact [text] needles.[/conditional]

POST TREATMENT
Recovery:
Tolerated procedure well and no complications were noted or reported. Condition stable. Able to self ambulate. Normal WOB. [textarea cols=20 rows=1].

Reported [checkbox name="reported" value="decrease in pain/symptoms|increase in pain/symptoms|no change in pain/symptoms"][textarea cols=20 rows=1].  

Verbally Instructed re: [checkbox name="instructions" value="exam findings|disease process|treatment provided||possible exacerbation of symptoms following acupuncture||recommendations|ROM exercise/stretching to prevent deconditioning||when and how to report possible side effects|when to contact emergency services||appropriate follow up|contacting PCP to address chronic health issues"][textarea cols=20 rows=1].

Disposition:
[checkbox name="disposition" value="discharged home,  RTC as discussed, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport|declined emergency transfer|left facility before being discharged|refered to medical department|"][textarea cols=20 rows=1].

FOLLOW UP
Plan for Further Care:
[checkbox name="further" value="continue with current treatment plan|follow up in one week|change frequency of visits to PRN|change treatment plan|released from care, max improvement reached|released from acupuncture d/t poor/aberrant response to treatment"][textarea cols=20 rows=1].

Barriers to Care:
[checkbox name="barriers" value="none identified|multiple comorbidities|chronicity of condition|lack of motivation|incomplete history|vague shifting complaints|intolerance of multiple meds and/or treatments|social/cultural barriers|preoccupation with illness|catastrophization|unrealistic beliefs|"][textarea cols=20 rows=1].
DOS:

Patient name:

DOB:


.

SUBJECTIVE
Head & Face:
.

Axial/CS:
.

Axial/TS:
.

Axial/LS:
.

Extremities:
.

Other symptoms:
.

Functional Assessment:
.

CC 1 – PROBLEM TO ADDRESS TODAY
CC/Dx:
.

Stated cause:
.

Previous Evaluations and Treatments:
.

- Timing:
.
- Frequency:
.
= Intensity:
best /10, worst /10.
- Laterality:
.
- Quality:
.
- Radiation:
.
- Worse with/at:
.
- Better with/during:
.

Problem_2

ROS
See attached Initial Health Status form for additional history, review of systems, medical history, social history, surgical history, diagnostic and laboratory studies.

PMH
See attached Initial Health Status form for additional history, review of systems, medical history, social history, surgical history, diagnostic and laboratory studies.


OBJECTIVE
VS:
.

Tongue Body:
.
Tongue coating:
.
Pulse:
.

General:
.

Posture & Gait:
.

Psychomotor Activity:
.

Behavior/Mental Status:
.

Neuro:
.

Face:
.

Cervical Spine:
.

Thoracic Spine & Chest:
.

Lumbar Spine:
.

Upper Extremity:
.

Lower Extremity:
.

Abdominal Palpation:
.

ASSESSMENT
Dx:
.

TCM PATTERN:
.

THERAPEUTIC GOALS
Provide symptomatic pain relief: pain level below .
Relieve muscle spasm in .
Increase blood circulation in .
Improve range of motion in in .
Promote general relaxation response.
Improve sleep.
Increase mobility.

INTERVENTIONS
Active Rehabilitation:
Emphasize patient responsibility, encourage early return to activity, promote therapeutic exercise/stretching, advise on life-style modification.
Cognitive restructuring:
How to live with pain and reasonable expectations.

Primary Modality:
Acupuncture.
Adjunctive Therapies:
.
Projected/Requested Services:
Dates of service: (today) through (6 weeks).
Visits: 6-8 treatments in total.
Frequency: once to twice per week, downgrade as symptoms improve.
Progress Towards Goals:
Re-evaluate every 3rd visit.
Positive patient response measured via functional gains such as positional tolerances, range-of-motion, strength, endurance, activities of daily living, cognition, and psychological behavior.
If no improvement, reconsider original diagnosis and/or modify therapeutic regimen.
Cease acupuncture If poor response or exacerbation of symptoms.
Consider:
Refer to specialty for detailed ortho / neuro examination.
Refer to PCP to address chronic health issues.
Refer to mental health to learn stress management.
Rehab Potential:
.

TREATMENT
Consent:
Procedure, R/B/A, potential SE, aftercare explained. Patient verbalized understanding & agreed w POC.
Treatment points localized based on TCM pattern, direct tenderness, local twitch response, proximity to problem area, spinal segment, and radiation patterns.
Primary Modality:


First Insertion:
Position:
.
Preparation:
Prior to needling,
.
Procedure:
Skin prepped w/ alcohol.
Inserted needles :
.
De Qi/twitch response .

Needles .

Electrical stimulation .

Removed and counted intact needles.

Insertion_2

POST TREATMENT
Recovery:
Tolerated procedure well and no complications were noted or reported. Condition stable. Able to self ambulate. Normal WOB.
.

Reported
.

Verbally Instructed re:
.

Disposition:
.

FOLLOW UP
Plan for Further Care:
.

Barriers to Care:
.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.48, 148 form elements, 397 boilerplate words, 14 text boxes, 62 text areas, 4 dates, 66 checkboxes, 2 conditionals, 691 total clicks
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