North American Institute of Medical Herbalism

North American Institute of Medical Herbalism

Case Review Format

Case-control information

Clinician______Case Number______Date______

Client Information

Gender ______Age ______Height ______Weight ______

Occupation ______

Caution with confidentiality – Include only occupational features that may be relevant to case, and report them generically

Interview Notes

Overall Health Rating

Chief complaint OPQRST

Secondary complaints OPQRST

Medical and drug information from Personal Intake Form (review and list potentially relevant side effects or withdrawal symptoms of all meds in a separate document. Include drugs of abuse.)

Previous adverse reactions to drugs or herbs, from Personal Intake Form

Compliance and Results (if follow-up)

Only new information below if follow-up

History Summary (General state of health, childhood illnesses, Adult illnesses, Psychiatric Illnesses, accidents and injuries, other trauma, operations, hospitalizations)

Social History Summary (Living situation, significant others, sexual history, occupation, financial situation, religious beliefs)

Lifestyle considerations (exercise, sleep patterns, diet, alcohol, recreational drugs, tobacco, coffee, soft drinks, chocolate, outlook on present and future)

Review of Systems

Include only those with positive findings.

Constitution hot, dry, moist, cold, excess, deficient, false heat, false cold, etc.

Please include a discussion of your rationale for constitutional assessment

Pulse Tongue

Speed Body Color

Width Coat Y/N?

Depth Coat color?

Impression To describe tongue areas, use 1-2-3 to describe front, middle, and back, and L and R for left and right

Clinician’s Case Analysis

Please include potential contributions of the SAD diet, broad-spectrum micronutrient deficiency, EFA deficiency, food intolerance, insulin resistance, eating disorder, trauma, and iatrogenesis to the case

Long Term Strategy (Overview of 4-6 month plan, if relevant to this case)

Short term plan: referrals, recommended reading, educational handouts given, verbal education, supplementation, herbs or formulas. Do an action formula and an alternate formula for each formula.

Self Observation: What issues came up for you during and after the visit. Does the client’s illness reflect anything in you? How are your boundaries in the case?