Clinical Note

Client Information

First name

Last name

Client's Email

appointment_id

Treatment Information

Treatment time

Date

Time

Duration(Minutes)

Treatment Fee($)

Check

Informed consent revived
Treatment
Assessment

Therapist

First

Last

What kind of this treatment?

Traditional Chinese Medicine
Acupuncture
Osteopathy
Massage Therapy

Initial Treatment ?

Yes

Chief Complaint

Current Symptoms

Energy, Sleep, Appetite, Thirst, Sweating, Chills/Fever, Body Pains, Bowels, Urine, Menstruation

General Observations

Patient Progress Inquiry

Treatment plan progress, patient’s reaction to treatment, document patient’s refusal to follow   recommendations, contraindications, adjunct modalities/ treatment or procedures used.

Examinations

Tongue

Pulse: Left

Pulse: Right

Palpation

Patient Medical History

Previous family health, ongoing problems, past illnesses/operations, prescription drugs, allergies, nutritional supplement, other health care provider’s referral and/or treatment plan

Diagnosis and Treatment

TCM diagnosis/ differentiations

TCM Treatment Principle

TCM Treatment Plan/ Advice

Acupuncture Points Prescribed (See Appendix)

Herbal Prescription

Name of herbs: Chinese Characters (Traditional or Simplified) or Pinyin (required) +  Medical Latinate or botanical name Type of herbs: Raw, powder, granular, sachets, packets, liquids, & extracts Quantity of herbs: e.g. 10 g Instructions for preparation and consumption Storage of herbs: e.g. store in cool and dry place Frequency of Treatment

Adjunct Modalities Cupping, Exercise, Dietary therapy Tui Na Therapy Gua Sha

Revised Diagnosis and Treatment

Revised TCM diagnosis/ differentiations

Revised TCM Treatment Plan/ Advice

Revised Acupuncture Points Prescribed (See Appendix)

Revised Herbal Prescription

Name of herbs: Chinese Characters (Traditional or Simplified) or Pinyin (required) + Medical Latinate or botanical name (required) Type of herbs: Raw, powder, granular, sachets, packets, liquids, & extracts Quantity of herbs: e.g. 10 g Instructions for preparation and consumption Storage of herbs: e.g. store in cool and dry place Frequency of Treatment

Adjunct Modalities

Cupping Exercise Dietary Therapy Tui Na Therapy Gua Sha

SOAP

S – Subjective (Patient Reported Symptoms & History)

Primary complaints (check all that apply): 

Other:

Details of symptoms: 

Onset Date:

Pain Intensity (0–10):

Duration:

Acute (≤1 month)
Subacute
Chronic (>3 months)

Frequency:

Aggravating Factors:

Relieving Factors:

Associated symptoms:

Treatment Goals:

O – Objective (Practitioner Observation)

Tongue Observation: 

Pulse Quality: 

Palpation Findings: 

Tender Points
Tense Muscles
Cold / Warm areas noted
Skin abnormalities:

Tender Points – Area:

Tense Muscles – Area:

Cold / Warm areas noted – Location:

Skin abnormalities:

Bruising
Rash
Nodules

Joint / Range of Motion issues: 

Other Clinical Observations: 

Fatigue visible
Shallow Breathing
Poor Posture
Emotional Signs:

Emotional Signs:

A – Assessment (Differential Diagnosis / Pattern Recognition)

Traditional Chinese Medicine Patterns: 

Other:

Modern Medical Assessment (optional):

Treatment Principle:

P – Plan (Treatment & Recommendations)

Treatment Provided: 

Areas Treated: 

Primary Acupoints Used:

Retention Time(minutes ):

Patient Reaction: 

Other:

Home Recommendations: 

Dietary advice:

Next Appointment:

S – Subjective (Patient-Reported Symptoms & History)

Primary Complaints osteo (check all that apply): 

Other：

Pain Level (0–10):

Onset Date:

Pain Duration:

Acute
Subacute
Chronic

Pain Frequency:

Constant
Intermittent

Aggravating Factors:

Relevant Medical History:

Patient’s Goal:

O – Objective (Practitioner Observations)

Postural Assessment: 

Palpation Findings(Osteo): 

Tender Points / Trigger Points – Location:

Mobility / Functional Tests: 

Other Findings:

A – Assessment (Clinical Impression)

Osteopathic Hypothesis / Diagnosis: 

Somatic Dysfunction – Region(s):

Summary / Clinical Reasoning: 

P – Plan (Treatment and Recommendations)

Treatment Techniques Used: 

Regions Treated: 

Treatment Duration: _____ minutes 

Patient Response: 

Good Tolerance
Mild Discomfort
Immediate Improvement

Home Advice / Education: 

Referral：

Recommended Follow-up:

1x/week
2x/month
Maintenance Plan

Next Appointment:

Treatment Plan

Yes

Type / Focus of treatment:

Areas to be treated:

Other areas to be treated:

SOAP

S – Subjective (Client-reported symptoms & history)

Symptoms & history

Joint stiffness – Location:

Limited mobility – Area:

Numbness or tingling – Area:

Pain rating (0–10):

Onset of issue:

Pain frequency:

Constant
Intermittent
Only after activity

Impact on daily activities:

Yes
No

If yes, how:

Client goals for today:

O – Objective (Therapist’s clinical observations)

Postural presentation: 

Palpation findings(Massage): 

Muscle tightness – Area:

Trigger points – Area:

Tenderness or sensitivity – Location:

Skin condition:

Normal
Redness
Bruising
Rash

Range of Motion (ROM) limitations: 

Cervical – Flexion / Extension / Rotation / Side-bending
Shoulder – Abduction / Flexion / Rotation
Lumbar – Flexion / Extension / Rotation
Hip or knee restrictions

Other testing/observation: 

Gait analysis (if applicable)
Client movement patterns noted:

Client movement patterns noted:

A – Assessment (Clinical impressions)

Detail

Muscle overuse or repetitive strain injury
Myofascial pain syndrome / Soft tissue dysfunction
Postural imbalance from sedentary work
Stress-induced musculoskeletal tension
Recovery phase of sports/training exertion
Mobility limitation affecting function
Mild inflammation noted
Referral may be needed (if serious signs/symptoms noted)

Clinical Summary:

P – Plan (Treatment provided and home care)

Treatment duration(minutes ):

Treatment techniques used:

Swedish massage (general relaxation)
Deep tissue massage (targeted release)
Trigger point therapy
Myofascial release
Joint mobilization / passive stretching
Cupping / Gua Sha / Heat application

Areas treated:

Client feedback during session:

Positive response
Minor discomfort
Asked to reduce pressure
Requested more focus on:

Requested more focus on:

Homecare suggestions: 

Gentle stretching exercises – Area:

Suggested treatment plan:

Return in 1 week
Return in 2 weeks
Monthly maintenance
Before/after sports

Next appointment:

Signature

Clear Signature

noted: Hydrotherapy

Date / Time

Date

Time

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Client Information

Treatment Information

Examinations

Tongue

Pulse: Left

Pulse: Right

Diagnosis and Treatment

Revised Diagnosis and Treatment

SOAP

S – Subjective (Patient Reported Symptoms & History)

O – Objective (Practitioner Observation)

A – Assessment (Differential Diagnosis / Pattern Recognition)

P – Plan (Treatment & Recommendations)

S – Subjective (Patient-Reported Symptoms & History)

O – Objective (Practitioner Observations)

A – Assessment (Clinical Impression)

P – Plan (Treatment and Recommendations)

S – Subjective (Client-reported symptoms & history)

O – Objective (Therapist’s clinical observations)

A – Assessment (Clinical impressions)

P – Plan (Treatment provided and home care)

First name	Test
Last name	Meng
Client's Email	mfsheng@gmail.com
appointment_id	13
Treatment time	09/12/2025 11:30 AM
Duration(Minutes)	60
Treatment Fee($)	250
Check	Informed consent revived Treatment Assessment
Therapist	Francis Meng
What kind of this treatment?	Massage Therapy
Symptoms & history	Limited mobility
Pain frequency:	Constant
Impact on daily activities:	No
Postural presentation:	Pelvic tilt or imbalance
Palpation findings(Massage):	Trigger points: Skin condition:
Range of Motion (ROM) limitations:	Hip or knee restrictions
Detail	Mobility limitation affecting function
Treatment techniques used:	Myofascial release
Areas treated:	Lower Back
Homecare suggestions:	Posture adjustment reminders
Suggested treatment plan:	Return in 2 weeks
Date / Time	09/12/2025 10:30 AM

First name	Paul
Last name	Wu
Client's Email	gzpaulwu2008@gmail.com
appointment_id	10
Treatment time	09/05/2025 9:30 PM
Duration(Minutes)	60
Treatment Fee($)	120
Check	Informed consent revived Treatment Assessment
Therapist	Paul Wu
What kind of this treatment?	Massage Therapy
Treatment Plan	Yes
Treatment Plan for:	Www
Date	09/05/2025
Limitations of activities of daily living:	Eee
Treatment plan discussed with Client:	Yes
Clients Goal / Treatment Goal:	Eee
Received informed consent for treatment plan:	Yes
Type / Focus of treatment:	Eee
Frequency:	2
Duration:	60
Areas to be treated:	back arm L arm R neck shoulders
Assessments Performed:	Palpation
Anticipated Progression of Responses:	Reduce tension
Results of Assessments:	Tight
Symptoms & history	Neck/shoulder stiffness or pain
Pain rating (0–10):	5
Onset of issue:	Eee
Pain frequency:	Constant
Impact on daily activities:	No
Client goals for today:	Eee
Palpation findings(Massage):	Muscle tightness:
Muscle tightness – Area:	Eee
Range of Motion (ROM) limitations:	Cervical – Flexion / Extension / Rotation / Side-bending
Detail	Muscle overuse or repetitive strain injury
Clinical Summary:	Eee
Treatment duration(minutes ):	60 min
Treatment techniques used:	Swedish massage (general relaxation)
Areas treated:	Neck Shoulders
Client feedback during session:	Positive response
Homecare suggestions:	Gentle stretching exercises –
Gentle stretching exercises – Area:	Neck
Suggested treatment plan:	Return in 2 weeks
Signature	https://omnihealthwellness.com/wp-content/uploads/wpforms/657-d3525e118e5fe41a4b751e30cbc66237/signature-68bb994ba39be.png
Date / Time	09/05/2025 10:00 PM