1. Patient I.D.:_____________ 2. Date:______________ 3. Time Duration of Session:_______ min

4. Patient Complaints Prior to Treatment: ________________________________________________

5. Objective Body Assessments Prior to Treatment: (ie. symptoms, limitations in range of motion)

6. Auricular Diagnosis Observations: (regions of tenderness, conductance, or skin surface changes)

7. Auriculotherapy Treatments Used: 

Acupuncture Needles Transcutaneous Electric Stimulation  Electroacupuncture  Acupoint Pellets
Acupressure  Other: __________________________

8. Auricular Points Treated: Right Ear  Left Ear ".C" = Chinese point ".E" = European point

Point Zero  Shen Men  Autonomic  Thalamus  Endocrine  Tranquilizer  Cerebral

Forehead  Temples  Occiput  Cervical Spine  Thoracic Spine  Lumbar Spine

Shoulder  Elbow  Hand  Hip.C  Hip.E  Knee.C  Knee.E  Foot.C  Foot.E

Stomach  Lung  Liver  Kidney.C  Kidney.E  Adrenal.C  Brain  Muscle Relaxation

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© Copyright 2000 Free permission to use this form may be granted by writing to Dr. Terry Oleson at HCA at the following: