FORM ATF

Auriculotherapy Treatment Form

Right Ear

Left Ear

Indicate on the auricular images above those areas on the ear where reactive ear reflex points were found.

1. Therapist Name: _________________________

4. Sex:

Male

Female

5. Race:

2. Patient ID : ____________
White

6. Date of first session: ______________________

Black

Latino

3. Patient Age: ______

Asian

Other _____________

7. Number of Sessions: __________

8. Patient Complaints Prior to Treatment: (i.e. symptoms, range of motion) _______________________________

9. Auricular Diagnosis Observations: (i.e. regions of skin changes, tenderness, electrodermal conductance)

Acupuncture Needles Electroacupuncture Acupressure

Acupoint Pellets Laser Other: _______________________

10. Auriculotherapy Treatments Used:

Transcutaneous Stimulation
11. Auricular Points Treated:

12. Patient Experience and Body Assessments Following Treatment: _____________________________

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Copyright 2009 Free permission to copy and use this form is granted by the Auriculotherapy Certification Institute (ACI) 501(c)3.
Web: www.auriculotherapy.org

PMB 270, 8033 Sunset Blvd., L.A. CA 90046-2401

(323) 656-2084

terry.oleson@gmail.com