full name
NHI number (if available)
date of birth
gender
ethnicity
contact details
residency status
name of the Primary Health Provider(GP)
Emergency contact
Date of treatment
The presenting complaints
The principal/primary diagnosis
Relevant associated conditions or additional diagnoses
Relevant family or personal history
Medications
subjective assessment
objective assessment
Analysis of clinical signs and symptoms
Relevant outcome measurements
Treatment goals and management plan
Information given to tangata whai ora
A record of a signed consent form or refusal
Today’s treatment Method, Retention,other techniques
herbal formula/prescriptions Herbal name:
Ingredients(English):
Referrals
any other interventions
Letters and reports to, or from, referring health professionals or other involved parties,clinical photographs and/or digital images
Note of risks and/or problems that have arisen and the action taken to rectify them
Electronic authentication or printed name, signature, and designation of the CM practitioner
responsible.
Follow up
Date of treatment
The presenting complaints
The principal/primary diagnosis
Relevant associated conditions or additional diagnoses
subjective assessment
objective assessment
Analysis of clinical signs and symptoms
Relevant outcome measurements
Treatment goals and management plan
Information given to tangata whai ora
A record of a signed consent form or refusal
Today’s treatment Method,Retention,other techniques
herbal formula/prescriptions Herbal name:
Ingredients(English):
Electronic authentication or printed name, signature, and designation of the CM practitioner
responsible.