Research report form of the image therapist
First paper sheet
The first part should contain information about the client’s first visit of Chinese image-medicine session. The information should be filled in two pages.
Link to the first paper sheet of the Form: PDF format and Word format.
In the form below, fill in the clients name and the date of birth.
Column 1.1. contains the information about the initial image seen in the diagnosis using the methods of Chinese Image-Medicine.
Column 1.2. filled with the clients words. This information serves to confirm the diagnosis made by the image, and helps to pay attention to the symptoms that the image has not shown.
In the column 1.3. Describes the diagnosis, based on the findings, references, analyzes and other information about the health of the client. All listed documents are formed as a separate application to the established Form.
Column 1.4. is planned to compile a study map, to choose the treatment and to appoint specialists of Chinese Image-Medicine.
The last line of the Form is filled with the date, name and surname of the Image Therapist.
Second paper sheet
The second paper sheet of the Form should contain information about the daily client’s sessions. Each session of Chinese Image Medicine is completed on a separate sheet. The template for sheet number two must be the same for each individual session.
Link to the second sheet of the Form: PDF format and Word format.
Let’s consider the filling recommendations of the second paper sheet in this Form.
In the upper part of the form we indicate the date and number of the Chinese image medicine session. In the column 2.1. fill out complaints about the health state coming from the client during repeated sessions.
Column 2.2. gives us the opportunity to record the changes in the client’s body. The method of fixation can be in the form of an ordinary photo, a medical photo, an analysis, the conclusion of another specialist, and so on.
Column 2.3. is planned for the description of the Chinese image-medicine methods which have been done by the specialist on a session with the specified date.
The name of the Column 2.4. speaks for itself. Current recommendations are to record at what stage of treatment, there have been changes in the state of client’s health.
The lower part of the daily records of this Form is signed by a specialist.
Third paper sheet
The sheet of the third established Form will contain information about the client’s health state after undergoing a course of treatment using Chinese Image-Medicine methods.
Link to the third sheet of the Form: PDF format and Word format.
In the field of Column 3.1. fix the results of research work from the Chinese Image Medicine point of view. The recording is performed in an arbitrary form.
The column 3.2. should contain the study results of the client’s health in terms of Western medicine methods. These can be the results of analyzes, medical images, conclusions and descriptions of specialists.
Column 3.3. can be filled both with the words of the client, and with his direct participation. The described sensations are supported by his signature.
Column 3.4. Describes the recommendations for maintaining health after a course of recovery using the Chinese Image-Medicine methods.
This 3.5 column is recommended to fill in in case of long client’s treatment. It can also serve as an aid in the study of a specific diseases and fix the obtaining period of the treatment result.
On the bottom line of the Form the date, name and surname of the Image Therapist is indicated.
This sheet is an addition to the second part of the Form and prints in the condition that the image therapist recorded the changes in the image on one of the days of the client’s treatment course.
Link to the Form application: PDF format and Word format.