Form ATF

 

FORM ATF 

 

Aur Auricul icul otherapy Tre Treatment atment Form

Right Ear

Left Ear

 

Indicate on the auricular images above those areas on the ear where reactive ear reflex points were found.

1. Therapist Name: _________________________ 4.  Sex : □  Male □  Female    

2. Patient ID : ____________

3. Patient Age: ______

5. Race Race:: □   White  □  Black  □ Latino  □   Asian  □  Other  ___  ______ ______ ______ ____  _ 

6. Date of first session : ______________________ ______________________

7. Number of Sessions: __________

8. Patient Complaints Prior to Treatment : (i.e. symptoms, range of motion) motion) _______________________________

  9. Auricular Diagnosis Observations: (i.e. regions of skin changes, tenderness, electrodermal conductance) 

 

10. Auriculotherap  Auricul otherapy y Treatment Trea tments s Used Use d: □   Acupuncture Needles   □ Electroacupuncture □  Acup  Acupres ressur sure e  □   Transcutaneous Stimulation □   Acupoi Acu point nt Pellet Pel let s

□  Laser   □   Other : _______________________ _______________________

11. Auricular  Auricular Points Treated Treated:

12 . Patient Experience and Body Assessments Following Treatment: _____________________________  

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