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Auriculotherapy Treatment Form

Right Ear

Left Ear

ATF

Indicate on pictures above those areas on ear where reactive ear reflex points were found
Onset
End
1. Patient I.D.:_____________ 2. Date:______________ 3. Time:__________ 4. Time:_________
5. Patient Complaints Prior to Treatment: _______________________________________________
________________________________________________________________________________
6. Objective Body Assessments Prior to Treatment: (ie. symptoms, imitations in range of motion)
________________________________________________________________________________
________________________________________________________________________________
7. Auricular Diagnosis Observations: (i.e. regions of tenderness and electrodermal conductance)
________________________________________________________________________________
________________________________________________________________________________
8. Auriculotherapy Treatments Used: Acupuncture Needles Transcutaneous Stimulation
Electroacupuncture Acupoint Pellets Acupressure Other: ________________________
9. Auricular Points Treated: _________________________________________________________
________________________________________________________________________________
10. Patient Experience Following Treatment: ____________________________________________
________________________________________________________________________________
11. Objective Body Assessments Following Treatment : ___________________________________
|________________________________________________________________________________
[ For Office Use Only ] Clinic ID: ________________ Practitioner ID: ___________________
Copyright 1999 Free permission to use this form may be granted by writing to Dr. Terry Oleson at the following:
HCA, PMB 2657, 8033 Sunset Blvd., L.A., CA 90046 FAX: (323) 656-2084 E-mail: hca-la@worldnet.att.net

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