Patient Herb Instruction Form
Because most Western patients are not experienced taking Chinese herbal medicinals, it is
important to provide them with clear, simple, written instructions on how to take their Chinese
herbal medications. For pills and powders, this is easy and straight forward. For decocted Chinese
medicinals, this can be a bit more complicated. However, even if one prescribes bulk-dispensed
decocted formulas, one can design a preprinted form that can be quickly and easily personalized
for each patient. Below is a sample of one such form.
Sample Herbal Instruction Form
Pills (tablets, capsules):
1. ____________ (pill name or identifier)
Take ____ pills each time, _____ times per day (before) (after) (with) meals.
2. ____________ (pill name or identifier)
Take ____ pills each time, _____ times per day (before) (after) (with) meals.
3. ____________ (pill name or identifier)
Take ____ pills each time, _____ times per day (before) (after) (with) meals.
Powders:
1. ____________ (powder name or identifier)
Take ______ spoonfuls (of the spoon provided), _____ times per day (before) (after) (with
meals).
2. ____________ (powder name or identifier)
Take ______ spoonfuls (of the spoon provided), _____ times per day (before) (after) (with
meals).
3. ____________ (powder name or identifier)
Take ______ spoonfuls (of the spoon provided), _____ times per day (before) (after) (with
meals).
Decoctions:
Take one packet of herbs and add to ____ Cups of water in a ceramic or glass pot. Soak for ½
hours. Bring to a boil. Then cook at (high) (medium) (low) heat for ______ minutes.
If any packets marked “precook,” cook these ingredients first in ____ Cups of water for _____
minutes and then add main packet of herbs and follow above instructions.
If any packets marked “add later,” add these ingredients during the last ____ minutes of cooking.
If any packets marked “steep,” add these ingredients after heat has been turned off and allow to
steep for _______ minutes.
Strain out the medicinal liquid and reserve.
Take ______ C of this liquid _____ times per day (warm) (cool) (on an empty stomach) (before)
(after) (with) meals.
Additional instructions: