Appendix 3: Case Record (Daily) Form
Date of Visit：
Department:
Patient Name:
Age:
Gender:
Occupation:
Chief Complaints:
Case History: (Including current illness, pass illness, personal history, family history and etc.)
Medical Check-up: (physical check-up, gynaecology examination and etc.)
Laboratory Tests: (If any)
Analysis of Aetiology and Pathogenesis:
Diagnosis of Western Medicine:
Diagnosis of TCM:
Syndrome Diagnosis:
Management/Observation: (Including herbal medicine and acupuncture treatment)
Major Herbal Formula:
COMMENTS of Preceptor (IF ANY)
Intern Name: ____________________________ Signature of Preceptors: _________________________
Intern Signature: _________________________ Date: _________________________________________