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1) Chief complaint

 

2) Biomedical Dx and supporting lab tests

 

3) Relevant Medical History, include habits, diet, exercise, etc.

 

4) questioning examination (subjective)

 

5) pulse and palpation examination (objective)

 

6) tongue and observation examination (objective)

 

7) the pattern(s) and treatment principles you chose, including your

rationale (unless this is your question) (assessment)

 

8) herbs used (unless this is your question) (plan)

 

9) other treatments or lifestyle changes

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