Traditional Chinese Medicine Diagnostic 10 Questions Please answer each question.

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1 1 Traditional Chinese Medicine Diagnostic 10 Questions Please answer each question. 1. Thinking about your internal thermostat and where you feel your body temperature is most of the day, do you think that you are usually (Circle One) a. Hotter than those around you b. Colder than those around you c. Same as those around you. 1a. Do you have hot flashes? Y N 1b. Do you have cold hands and feet? Y N How thirsty you usually feel? (Circle one) 1c. Not Thirsty at all 1d. Normal thirst for environmental conditions 1e. Very Thirsty 2. Do you sweat when you exercise? Y N 2a. Do you sweat when sitting quietly? Y N 2b. Do you have night sweats? Y N 2c. Do you think that you sweat excessively? Y N 3. Do you wake feeling rested? Y N 3a. Do you have trouble falling asleep? Y N 3b. Do you have trouble staying asleep? Y N 3c. How many times do you wake at night? 3d. What time of night do you typically awaken? 4. Do you get hungry? When you eat, do you get full? Y N 4a. Do you crave sugar? Y N 4b. Do you crave salt? Y N 4c. Do you have any other flavor cravings? 5. Do you consider your digestion normal? Y N 5a. Do you tend to have gas? Y N 5b. Do you tend to have bloating? Y N 5c. Do you tend to be constipated? Y N 5d. Do you tend to have diarrhea? Y N 5e. Do you tend to have bowel pain? Y N 5f. Do you tend to have frequent burping? Y N 5g. Do you tend to have frequent nausea? Y N

2 2 6. Do you wake up at night to urinate? Y N 6a. If you do, about how many times per night? 6b. Is your urine typically pale and clear? Y N 6c. Is your urine typically dark or concentrated? Y N 6d. Do you lose your urine when you cough, sneeze or have a full bladder? Y N 7. Are you still having a menstrual period? Y N If you are not still having a menstrual period, please answer the following based on your most typical menstrual period in the past. 7a. Were or are your periods regular? Y N 7b. Did you or do you have blood clots larger than a nickel? Y N 7c. On the line below, mark the color of your menstrual blood from brighter red (R) to darker maroon (M)? R M 7d. Did or do you have severe pain with your periods? Y N 7e. Did or do you tend to have mood changes before your periods? Y N 7f. How many days did or do your period last? 7g. How many days were or are your cycles? 8. Do you typically have an energy drop at a certain time of day? Y N 8a. If you do have an energy drop, usually at what time of day? 8b. Mark on the line where your energy is right now using the scale: 0 (no energy) to 10 (excessive energy) Place a mark on the line to indicate on a scale of 0 (none) to 10 (worst imaginable), to show how much pain are you having right now. 0 10

3 3 9a. Please tell us about your pain. Circle as many as apply: -Burning- -Dull- -Achy- -Sharp- -Stabbing- Better with: Pressure Warmth Cold Worse with: Pressure Warmth Cold 10. Place a mark on the line where you would characterize your predominant mood? Happy Sad Content Angry Carefree Worried Practitioner s Exam and Diagnostic Work Sheet Tongue Diagnosis Circle choices provided or write in other findings Body color: red pink pale Body quality: puffy significantly swollen thin fat other shape Body moisture: moist wet dry Coat color: White yellow gray black none other Coat thickness: thick thin Coat moisture: moist dry greasy Sublingual veins: flat distended engorged other Other significant tongue features: teeth indentations macules other

4 4 Pulses Right cun chi guan Left cun chi guan Quality of pulse: Choices: floating, flooding, empty, scattered, hollow, leather, soft, minute; sinking, hidden, firm, full, weak, thin, slow, leisurely, choppy, knotted, intermittent, rapid, slippery, tight, hasty, moving, long, wiry, short (Huynh & Seifert, 1981) Right Cun Guan Chi Left Cun Guan Chi Diagnosis Organs Involved: Rank Liver Kidney Spleen Heart Lungs Pericardium Gall Bladder Bladder Stomach Small Intestine Large Intestine Triple Burner

5 5 Diagnosis, Appearance and Other information: 52 Diagnosis: 1. Liver Qi Constraint: Liver Blood Xu: Liver Yin Xu: Liver Wind: Liver Yang Rising: Liver Heat: Liver Fire Blazing: Qi and Blood Stagnation: Heart Xu: Yin / Blood / Qi / Yang (Circle one. If more than one enter in Other): Spleen Qi Xu: Spleen Damp: Kidney Yang Xu: Kidney Qi Xu: Kidney Yin Xu: Kidney Jing Xu: Damp Heat Retention: Wind-cold invasion: Other: Other:

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