Diagnosis Steps

Chief Complaints
What, location, duration, causes
Aggravate/relieve: pressure, sit/stand, hot/cold, eating, BM, rest/activity
Characteristics: stabbing, dull, on/off, constant
Supporting signs & symptoms
Other: bleeding, smell, frequency, color, taste, itch, appearance, sputum, severity
8 principle: interior/exterior, hot/cold, Yin/Yang, excess/deficiency
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Questioning
Chills/Fever: internal/external, body temp., lowgrade fever, afternoon
Head & Body: pain, numbness, dizziness, headache, memory, mouth sores, heaviness
Torso: pain, cough, shortness of Breath, genitals, difficult swallowing, palpitations
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Eyes & Ears: pain, color, dry, tinnitus, blurry vision, poor night vision, floaters
Emotions: 7 emotions
Energy: out of 10, fatigue
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Sleep: difficult fall, light sleep, vivid dreams, rise early & difficult get back to sleep, snoring
Sex: STD's, birth control pill, noctural emissions, libido
Sweat: spontaneous daytime, night, location, color
Skin: eruptions, dryness, spots, varicose veins
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Digestion/appetite: appetite, hungry, gas, bloating, nausea, vomit
Elimination: BM, urine, hemorrhoids, bleeding
Thirst/taste: thirsty, bitter/sweet/bland taste in mouth, prefer what flavour
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Gynecology: menses, pregnancy, leukorrhea, prolapse
Lifestyle: income, exercise, stress, smoke, alcohol
History: disease, other treatments, trauma, operations, meds, blood pressure, lab tests, family, allergies, relations
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Palpation
Pulse
Body: lumps, abnormalities
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Hearing & Smelling
Voice, cough, sighing
Body odor, breath, stool, urine
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Observation
Spirit: eyes
Demeanour: restless, slow
Skin: eruptions, dry, itch, edema, color, venules, peticiae
Face: color, dull, bright, lusterous, expression
Hair: falling, greying, lustre
Lips & Mouth: color, dry, lustre, teeth
Eyes: color, spirit
Nails: color, brittle
Gait
Body Shape: skinny, obese, barrel chest
Tongue: shape, color, moisture, coat
