Traditional Chinese Medicine Prescription
Practitioner: [YOUR NAME], Licensed TCM Practitioner
Clinic/Institution: [YOUR COMPANY NAME]
1. Patient Information
Patient Name: | Chloe Emard |
|---|
Age: | 31 |
|---|
Gender: | Female |
|---|
Address: | Santa Ana, CA 92701 |
|---|
Contact Number: | 222 555 7777 |
|---|
Date of Visit: | January 12, 2055 |
|---|
2. Diagnosis
3. Treatment Principles
4. Prescription
Herb Name | Pinyin Name | Dosage | Function |
|---|
Codonopsis Root | Dǎng shēn | 15g | Tonifies Qi and strengthens the Spleen |
Poria | Fú líng | 12g | Strengthens the Spleen and drains Dampness |
Atractylodes Rhizome | Bái zhú | 9g | Tonifies the Spleen, dries Dampness |
Licorice Root | Gān cǎo | 6g | Harmonizes the formula, tonifies Qi |
Tangerine Peel | Chén pí | 6g | Regulates Qi and resolves Dampness |
Angelica Sinensis | Dāng guī | 9g | Nourishes and invigorates the Blood |
5. Dosage and Preparation Instructions
Decoction: Boil the above herbs in 1.5 liters of water. Reduce to 500 ml and drink twice daily (morning and evening), 250 ml each time.
Duration: 10 days of treatment, with a follow-up consultation.
6. Special Instructions
Avoid consuming cold or raw foods during the treatment to support digestive function.
Rest adequately to support Qi replenishment.
Monitor for any signs of improvement or adverse reactions and report them during the follow-up session.
7. Follow-Up
Next Appointment: January 22, 2055
Practitioner Comments: Adjust dosage based on patient’s response after 10 days.
Practitioner’s Signature:
Date: January 12, 2055
Prescription Templates @ Template.net
