Free Traditional Chinese Medicine Prescription Template
Traditional Chinese Medicine Prescription
Practitioner: [YOUR NAME], Licensed TCM Practitioner
Clinic/Institution: [YOUR COMPANY NAME]
1. Patient Information
|
Patient Name: |
Chloe Emard |
|---|---|
|
Age: |
31 |
|
Gender: |
Female |
|
Address: |
Santa Ana, CA 92701 |
|
Contact Number: |
222 555 7777 |
|
Date of Visit: |
January 12, 2055 |
2. Diagnosis
-
Main Diagnosis: Qi Deficiency (Qì xū)
-
Secondary Diagnosis: Dampness (Shī) in the Spleen
3. Treatment Principles
-
Tonify Qi (Bǔ qì)
-
Strengthen the Spleen (Jiàn pí)
-
Resolve Dampness (Huà shī)
4. Prescription
|
Herb Name |
Pinyin Name |
Dosage |
Function |
|---|---|---|---|
|
Codonopsis Root |
Dǎng shēn |
15g |
Tonifies Qi and strengthens the Spleen |
|
Poria |
Fú líng |
12g |
Strengthens the Spleen and drains Dampness |
|
Atractylodes Rhizome |
Bái zhú |
9g |
Tonifies the Spleen, dries Dampness |
|
Licorice Root |
Gān cǎo |
6g |
Harmonizes the formula, tonifies Qi |
|
Tangerine Peel |
Chén pí |
6g |
Regulates Qi and resolves Dampness |
|
Angelica Sinensis |
Dāng guī |
9g |
Nourishes and invigorates the Blood |
5. Dosage and Preparation Instructions
-
Decoction: Boil the above herbs in 1.5 liters of water. Reduce to 500 ml and drink twice daily (morning and evening), 250 ml each time.
-
Duration: 10 days of treatment, with a follow-up consultation.
6. Special Instructions
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Avoid consuming cold or raw foods during the treatment to support digestive function.
-
Rest adequately to support Qi replenishment.
-
Monitor for any signs of improvement or adverse reactions and report them during the follow-up session.
7. Follow-Up
-
Next Appointment: January 22, 2055
-
Practitioner Comments: Adjust dosage based on patient’s response after 10 days.
Practitioner’s Signature:
Date: January 12, 2055
