TCM Diagnosis by Asking - One of the 4 Pillars

Questioning or interviewing a patient during intake covers many topics, including:

Past medical history
Origin of the current problem
Living and environmental conditions
Current and past emotional issues, including family relationships, partner
relationships, work issues etc.
Eating patterns and Diet
Specific questions relating to bodily systems
Identification of TCM patterns is done by using paradigms such as the 8 Principles (Ba
Gong), Zang Fu organ diagnosis, Channel diagnosis, as well as other paradigms. Patterns
can be identified generally as in the 8 Principles, or more specifically as in Zang Fu
diagnosis.
Absence of a sign or symptom may, in some cases, be vital to a correct TCM diagnosis,
and absence of symptoms are generally not reported by a patient. For example, absence
of thirst may indicate a cold condition. Keep in mind that all relevant information is not
usually provided by the patient.
Traditionally, there are ten areas of questioning
Common areas of Questioning today:
Chills and Fever
Sweating
Head and Body
Thorax and Abdomen
Food and Taste
Stools and Urine
Sleep
Ears and Eyes
Thirst and Drink
Pain
Gynecological Conditions
Pregnancy and Childbirth (where appropriate)
Questions should be relevant to the patients condition, as not all questions are useful in
every situation. Additional questions should be asked based on information provided by
the patient as well as what is observed by the practitioner.
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Chills and Fever
Chills and Fever in Exterior Patterns
Chills and fever in an Exterior Pattern (unless they are alternating), an invasion or attack
by exogenous pathogenic factors. It is important to distinguish the presence of chills or
fever or both. Chills is not only the feeling of Cold, but also having an aversion to Cold.
The patient does not want to go outside into the Cold, does not like drafts, and the chills
are not alleviated by covering up with blankets. Fever, in this context, is a subjective
sensation of heat rather than actual body temperature.
The initial stages of an Exterior diseases is an acute condition, like the flu or common
cold. When a patient has an aversion to cold and chills, it usually indicates an invasion of
exogenous Wind Cold or exogenous Wind Heat. The patient feels cold because the
pathogenic factor blocks circulation of the body's Defensive Qi (Wei Qi), which is
impaired from circulating and warming the body. The chills and fever occur
simultaneously at the beginning stages of an acute disease because the body is trying to
expel the pathogen. This is the pathogenic/evil Qi struggling with the
antipathogenic/protective Qi.
Wind Cold
Symptoms: chills, aversion to cold, possible fever (especially low grade), usually with
body aches, absence of sweating, headache.
Pulse: superficial/floating and tight.
Wind Heat
Symptoms: Predominantly fever, with only slight aversion to cold or mild chills. Also
thirst, slight or profuse sweating.
Pulse: superficial/floating and rapid.

Alternating Fever and Chills
This is a half external and half internal condition where there is exterior invasion of
Wind-Cold or Wind-Heat, but the pathogen has penetrated to a deeper level (Shaoyang)
of the body .

Exterior diseases are generally diagnosed according to two paradigms:
The Six Stages (Taiyang, Shaoyang, etc.)
The Four Levels (Wei, Qi, Ying, Blood).
Chills and Fever in Interior Patterns
Interior Excess Heat patterns usually present with a persistent high fever and aversion to
heat, but no chills. Other symptoms may include profuse sweating, thirst, and a flooding
pulse.
Interior Deficient Heat patterns usually present with tidal fever (fever that comes in
'tides', at specific hours of the day, usually in the evening or night). Other symptoms
may include night sweats, 5 palm heat (heat or sweating in the palms of the hands,
soles of the feet, and the chest), and a red tongue body.
Chills without fever usually indicates interior Cold from Deficiency of Yang
If chills are alleviated by covering up with blankets, there will be other
symptoms such as cold limbs, and a deep, slow and weak pulse.
A constant low-grade temperature usually indicates Damp Heat
Fever in the middle of the night
With an adult: This usually indicates Yin Deficiency, especially if
accompanied by Night Sweats
With a child: Retention of Food
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Sweating
It is usually beneficial to ask a patient about sweating, even if they don't initially
volunteer the information.
Example Questions:
Do they sweat easily or excessively, and at what times?
Do they have spontaneous sweating without exertion?
In Exterior Patterns sweating can indicate:
Wei Qi (Defensive Qi) is weaker than the pathogenic Qi and can not expel the
pathogen.
When other heat signs are present, it may indicate Exterior Wind Heat. If
perspiration breaks the fever, the pathogen has been expelled.
No sweating is usually an Excess Cold pattern, where cold blocks the pores.
In Interior Patterns sweating is differentiated by:
Time of day
Day time spontaneous perspiration (without exertion) indicates Yang or Qi
Deficiency. Wei Qi can not regulate the pores.
Night time sweats are usually Yin Deficiency. Relative excess of Heat
causes pores to open during the Yin most times.
Area of body
Sweating on the head is usually Stomach Heat or Damp-Heat
Oily sweat on forehead may indicate Collapse of Yang
Sweating only on the arms and/or legs is Stomach and Spleen Deficiency
Sweating only on hands indicates Lung Qi Deficiency or mental anxiety.
Sweating over the whole body indicates Lung Qi Deficiency
Five palm heat (palms of the hands ,soles of the feet, and the chest
indicates Yin Deficiency
Condition of illness
Profuse cold sweat during severe illness indicates Yang Collapse
Oily sweat on forehead that are not flowing and looks like pearls may
indicate imminent death from Yang Collapse
Quality of Sweat
Oily sweat indicates severe Yang Deficiency
Yellow sweat indicates Damp Heat
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Head and Body
The Head is where all six Yang channels meet. The three Yang channels of the upper
limbs end on the face and the three Yang of the lower limbs begin on face. Yang
channels bring the clear Yang to the head and orifices, enabling clear vision, hearing,
taste, and smell.
Headache
Headache is distinguished according to the onset, time, location, nature of the pain,
condition.
Onset
Sudden onset and of short duration indicates exterior attack of Wind cold
disturbing the Yang or Qi in the head.
Chronic headaches are often attributed to an interior condition.
Time of Day
Daytime headache indicates Qi or Yang Deficiency
Evening headache indicates Blood or Yin Deficiency
Location
Occipital headache indicates Taiyang channels (BL, SI). Usually caused by
Exterior Wind-Cold or Kidney Deficiency
Frontal headache indicates Yangming channels (LI, ST). Often caused by
Stomach Heat or Blood Deficiency, but can also be caused by exogenous
Wind.
Temporal or parietal headache indicates Shaoyang channels (GB, SJ).
Usually caused by exterior Wind-Cold or Wind-Heat in Shaoyang, or Rising
Liver Fire affecting Gall Bladder channel.
Vertex headache indicates Jueyin channels (LIV). Usually caused by
Deficient Liver Blood
Whole head headache usually indicates severe Exterior Wind-Cold, or may
indicate mild Deficiency of Blood and Qi.
Nature of Pain
A heavy sensation is usually due to Dampness or Phlegm
'Pain inside the brain' is usually due to Kidney Deficiency
Distending, throbbing, or bursting pain is usually associated with
Ascending Liver Yang
Fixed pain in one area with a boring sensation into the head is usually due
to Blood Stagnation
Condition
Headache with aversion to wind or cold usually indicates Exterior invasion
of pathogenic factors
Headache that is worse with Cold indicates a Cold Pattern
Headache that is worse with Heat indicates Heat Pattern
Headache that is worse when fatigued, better when at rest usually
indicates Qi Deficiency
Dizziness
Dizziness can be due to Internal Wind, Fire, Phlegm, or Deficiency of Qi and Blood
Internal Wind from Ascending Liver Fire
Dizziness with loss of balance, often with such signs as tinnitus, headache,
nausea, red eyes, wiry pulse, irritability, and other characteristic signs of
Ascending Liver Yang
Phlegm
Mild to severe dizziness with heavy and "foggy" feeling in the head plus
other signs e.g. nausea, excessive sputum, slippery pulse. Phlegm
obstructs the head, so that the clear Yang cannot ascend.
Qi and Blood Deficiency
Slight dizziness, worse when fatigued, accompanied by such signs as
fatigue, perhaps palpitations and difficulty falling asleep, pale tongue and
weak pulse.
Acute Onset of Dizziness
Indicates an Excess pattern
Gradual Onset or Chronic Dizziness
Indicates a Deficiency pattern
Pain All Over the Body
Pain that has sudden onset and is accompanied by chills and fever is due to an
invasion of exterior Wind, usually Wind-Cold.
Pain all over the body with fatigue is usually deficiency of Qi and Blood
Postpartum women with dull pain usually indicates Deficient Blood
Postpartum women with severe, fixed or stabbing pain usually indicates Blood
Stasis
Muscle pain with hot sensation is usually due to Stomach Heat
Pain with a feeling of heaviness is usually due to Dampness obstructing the
muscles
Pain in the Joints, Painful Obstruction Syndrome (Bi Syndrome)
Wandering Bi Pain is usually from wind.
Fixed and very painful joints that are worse in cold weather and improved with
heat indicates Cold Bi.
Fixed pain with numbness and heaviness that is worse when Damp outside
indicates Damp Bi.
Joint pain with swelling and heat in joints may indicate Wind Cold and Damp have
turned to heat.

Lumbar Pain
Continuous dull pain that is better with rest indicates Kidney Deficiency
Severe pain and stiffness with recent onset indicates lumbar sprain caused by
Blood Stasis
Severe pain that is worse in cold and damp but improved by heat indicates an
invasion of exogenous Cold and Damp into the channels of the back.
Fixed and boring pain and an inability to turn at the waist indicates Blood Stasis
Pain that extends up to the shoulders, with other exterior symptoms such as
headache, stiff neck, nasal congestion, etc. indicates exterior Wind attack.
Numbness
Bilateral numbness of the hands and feet, or arms and legs, usually indicates
Blood deficiency
Numbness of fingers (especially the 1st 3 digits), numbness of the elbow and arm
on one side is usually internal Wind and Phlegm (impending Wind-stroke).
Thorax and Abdomen
Areas of the thorax and abdomen can be generally associated with the internal organs
Thorax: Heart and Lungs, Upper Jiao
Flanks and Ribcage: Liver and Gallbladder
Abdomen: Liver, Intestines, Spleen, Kidney, Bladder
Epigastric area: Spleen and Stomach
Umbilical area: Kidney
Chest Pain
Chest Pain is often Blood Stasis in the Heart from Deficient Yang.
Chest Pain with Cough and copious Yellow Phlegm indicates Phlegm-Heat in Lung.
Hypochondriac Pain
Distention or Discomfort in the hypochondriac region is usually Liver Qi
Stagnation.
Severe hypochondriac pain is usually indicative of Liver Blood Stasis.
Epigastric Pain
Can be due to Liver Qi Stagnation or Stomach Heat.
If the pain is dull, it may indicate retention of food in the stomach.
If the pain is better after eating or applying heat it may indicate Deficient Cold in
Stomach.
If the pain is worse after eating it may indicate a Deficient pattern.
If there is also fullness in the epigastrium, this indicates an Excess pattern
Lower Abdominal Pain
If relieved by defecation, this indicates Excess
If worse on defecation, this indicates Deficiency
Causes
Internal Cold
Stagnation of Liver Qi
Stagnation of Liver Blood
Retention of food in Intestines
Blood Stasis in the Intestines
Blood Stasis in the Uterus
Damp Heat in Intestines
Hypogastric Pain
Can be caused by Damp-Heat in the Bladder.
Can be caused by Liver Fire coursing down into the Bladder.
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Food and Taste
This gives us information regarding the state of Spleen & Stomach (also the flavors
desired give clues to other Organs according to the five element correspondences).
Appetite and Eating
Condition relieved by eating indicates a Deficiency pattern
Condition aggravated by eating indicates an Excess pattern
Lack of appetite indicates Deficient Spleen Qi
Always hungry even after eating indicates Stomach Heat
Fullness/distention after eating indicates Retention of Food
Prefers warm food indicates a Cold Pattern
Prefers cold food indicates a Heat Pattern
Taste in Mouth
Bitter taste is usually due to an Excess Heat pattern (Liver or Heart)
A constant bitter taste in the mouth is usually due to Liver Fire
A bitter taste in the morning after no sleep is usually due to Heart Fire
A sweet taste may indicate Spleen Deficiency or Damp Heat
A sour taste is usually due to retention of food in Stomach or the Liver invading
the Stomach
A salty taste is usually due to Kidney Yin Deficiency
A pungent taste is usually due to Lung Heat
Vomit
Sour vomiting may indicate Liver Invading Stomach
Clear/Watery vomiting may indicate Cold in Stomach with Fluid retention
Vomiting after eating may indicate a Heat Pattern
Sudden & Loud vomiting may indicate Excess pattern
Slow & Weak vomiting may indicate Deficiency pattern
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Stools and Urine
A condition alleviated after bowel movement indicates an Excess condition, while a
condition worsening after bowel movement indicate a Deficiency condition.
Constipation
Acute constipation with infrequent dry stools, accompanied by thirst, and a dry
yellow tongue coating indicates heat in stomach and intestines
Constipation in elderly, or women postpartum indicates Deficient Blood and Fluids
Constipation with small, bitty stools indicates Liver Qi Stagnation and Heat in
Intestines
Difficult bowel movements with stools that are not dry indicates Liver Qi
Stagnation
Constipation with abdominal pain indicates Internal Cold and Yang Deficiency or
Liver Qi Stagnation
Constipation with dry stools and no thirst indicates Kidney or Stomach Yin
Deficiency
Alternating constipation and diarrhea indicates Liver Qi invading the Spleen
Diarrhea
With pain indicates Stagnation of Liver Qi, or Liver Heat, or interior Heat or Cold
in the Intestines
Foul odor, especially if urgent indicates Heat
Urgent diarrhea or loose stools with burning sensation in the anus indicates Heat
Absence of odor indicates Cold
Chronic diarrhea indicates Deficient Kidney or Spleen Yang failing to transform
food and fluid
Chronic, daily, and early morning (cocks crow diarrhea) indicates Kidney Yang
Deficiency
With mucous indicates Dampness in the Intestines
Frequent watery or unformed stools indicates Deficient Yang, Deficient Qi, or
Dampness
Loose stools with undigested food indicates Deficient Spleen Qi or Deficient spleen
Yang
Frequent or urgent stools that are not loose or only slightly loose indicates
Sinking of Spleen Qi or Spleen and Stomach Qi Deficiency
Black or very dark stools indicates Blood Stagnation
With Blood indicates a Heat condition (A patient with Blood in the stool should
always be referred to a western physician to rule out Cancer)
Borborygmus (gurgling in the abdomen)
With loose stools indicates Spleen deficiency
With abdominal distention but no loose stool indicates Liver Qi Stagnation
Flatulence
Stagnation of Liver Qi is often involved
With foul odor indicates Damp-Heat in Spleen, Stomach Heat, or Stagnant Qi in
the Small Intestine
Without odor indicates Deficient Spleen Yang producing interior Cold
Urinary Function
Enuresis/incontinence indicates Kidney Yang Deficiency
Retention of urine indicates Damp Heat in Bladder
Difficult urination, especially with painful and dark urine, indicates Damp-Heat in
Bladder
Inability to complete urination, dribbling, or lack of force in urination indicates
Kidney Qi Deficiency, Dampness, or Cold
Frequent and copious urination, especially at night, indicates Kidney Yang
Deficiency
Frequent and scanty urination indicates Kidney Qi deficiency
Frequent, scanty, and dark urination indicates Damp-Heat in Bladder
Pain associated with urination
Before urination indicates Stagnation of Qi in the Lower Jiao
During urination indicates Heat in Bladder
After urination indicates Deficiency of Qi
Urine Color
Pale indicates Cold of the Bladder and Kidney, usually from deficient
Kidney Yang
Dark, yellow, or reddish indicates Heat
Turbid or Cloudy indicates Dampness in bladder
Urine Amount
Large amounts indicates Kidney Yang Deficiency
Scanty amount indicates Heat or Dampness obstructing Bladder, Deficient
Fluids, or Kidney Yin Deficiency producing Empty Heat
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Sleep
The Heart is the residence of the Shen, and the Blood and Yin nourish the Shen. When
Blood and/or Yin is Deficient, the Shen has no residence and can not rest.
Unable to fall asleep but sleeps well once asleep is usually due to Deficient Heart
Blood
Waking often during night is usually Heat disturbing the Shen
This can be due to Kidney Yin failing to nourish Heart Yin, Stomach Heat from
retention of food, etc.
Waking early or unable to fall asleep again indicates Gallbladder Deficiency. This
is common in the elderly as Qi and Blood are weaker.
Dream-disturbed sleep usually indicates Liver Fire and/or Heart Fire
Liver Fire and Heart Fire can be due to Kidney Yin Deficiency
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Ears and Eyes
The Kidney opens to the ears, but not all ear disorders are related to the Kidney. The
Shaoyang channels (GB, SJ) travel to the ears, and some Exterior Heat conditions that
affect the Shaoyang can cause ear problems. Dampness and Phlegm can also obstruct
rising of Yang to upper orifices which can affect the ears.
Tinnitus (Ringing in the Ears)
Sudden onset indicates Excess condition, usually of Liver Fire or Liver Wind
Gradual onset indicates Kidney Deficiency
Aggravated by pressing on ears indicates Excess
Alleviated by pressing on ears indicates Deficiency
Loud, high pitched noise like whistle indicates Rising Liver Yang, Liver Fire, or
Liver Wind
Low pitched noise like rushing water indicates Kidney Deficiency
Deafness
Sudden onset indicates Excess condition, usually Liver Fire or Liver Wind
Gradual onset and chronic deafness indicates Deficiency, usually of the Kidney, or
of Heart Blood Deficiency, or Yang Deficiency
Eyes
Pain, swelling, and redness indicates Invasion by Exogenous Wind-Heat or
internal Liver Fire
Blurry vision and floaters indicates Liver Blood Deficiency
Photophobia indicates Liver Blood Deficiency
Pressure in eyes indicates Kidney Yin Deficiency and/or Liver Fire
Dryness of eyes indicates Liver/Kidney Yin Deficiency
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Thirst ad Drink
For cold liquids indicates Heat
For warm liquids indicates Cold
Thirst for large amounts of Cold Water indicates an Excess Heat Pattern
No Thirst indicates Cold pattern, usually of the Stomach or Spleen
Thirst with no desire to drink indicates Damp-Heat
Thirst with desire to sip liquids slowly, or sip warm liquids indicates Yin Deficiency
(of Stomach or Kidney)
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Pain
Excess conditions causing pain are usually due to Qi circulation in the Channels being
obstructed due to stagnation, cold, or heat. Deficient condition that cause pain are
usually due to the channels not being nourished by Yin and Blood. An Excess condition
causes more severe pain, while a deficient one causes more dull pain.
Excess Conditions
Invasion of exogenous pathogens
Interior Cold or Heat
Stagnation of Qi (causes distention more than pain, or vague distending
sensation without location)
Stasis of Blood, usually causes severe, localized, fixed, or boring pain
Obstruction by Phlegm
Retention of Food
Deficient Conditions
Deficient Qi and Blood
Deficient Yin with consumption of Body Fluids

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Gynecological Conditions
Ask about Menstruation, Vaginal Discharge, Pregnancy, and Childbirth. A Woman's
menses give a clear idea of the condition of her Qi and Blood.
Important questions
Length
Duration
Amount of bleeding
Color
Quality of flow
Pain or other symptoms, before, during and after flow
Cycle
Early arrival of period indicates Heat in the Blood (red tongue) or Qi Deficiency
(pale tongue)
Late period indicates Blood Deficiency, Blood Stagnation, or Cold
Irregular period indicates Stagnation of Liver Qi or Deficient Spleen Qi
Amount
Heavy blood loss that is bright red indicates Heat in Blood, while pale and more
scanty blood indicates Spleen Qi Deficiency
Abnormal Uterine Bleeding indicates Heat in Blood, Deficient Spleen Qi, Stagnant
Qi or congealed Blood, or Deficient Liver/Kidney Yin
Scanty periods indicates Blood Deficiency or Stagnation of Blood or Cold
Obstructing
Amenorrhea indicates Deficient Blood and Qi, Stagnant Qi/Blood Stasis, Deficient
Kidney/Liver Yin, Mucus dampness Obstructing Menses
Color
Normal color is a dull to medium red
Very dark red or bright red Indicates Heat in the Blood
Pale blood Indicates Deficiency of Blood
Purple/blackish blood Indicates Stasis of Blood or Cold
Quality
Congealed blood with clots Indicates Blood stasis or Cold
Watery blood Indicates Blood or Yin Deficiency
Turbid blood Indicates Blood Heat or Stagnation of Cold
Pain
Before periods indicates Stagnation of Qi or Blood, Cold/Cold Damp Obstructing
During periods indicates Stagnation of Qi or Blood, Stagnation of Cold, or
Deficient Blood and Qi
After periods indicates Qi and Blood Deficiency
Leucorrhoea
Color
White, thin, clear indicates Cold from Spleen or Kidney Yang Deficiency,
Exogenous Cold Damp, or Stagnation of Liver Qi
Yellow, especially if thick and accompanied by vaginal itching or soreness
indicates Damp-Heat in the Lower Jiao
Red and white discharge indicates Damp Heat
Yellow, with pus and blood after menopause indicates Toxic Damp-Heat in
the Uterus (the patient should be referred to a western physician for a
complete gynecological exam)
Consistency
Watery indicates Cold Damp
Thick indicates Damp Heat
Odor
Little or no odor indicates Cold
Strong odor indicates heat
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Pregnancy and Childbirth
Pregnancy
Infertility due to Deficiency is usually because of Deficient Blood, Deficient Kidney
Jing, or Cold
Infertility due to Excess is usually because of Damp Heat in Lower Burner or
Stasis of Blood in Uterus
Vomiting during pregnancy indicates Stomach Heat, or Deficiency of Stomach and
Chong Mai
Miscarriage before three months may indicate Deficiency of Blood or Essence
(Kidney)
Miscarriage after three months may indicate Stasis of Liver Blood or Sinking of
Spleen Qi
Childbirth
Nausea and heavy bleeding after delivery indicates Exhaustion of Chong Mai
Sweating and fever after delivery indicates Exhaustion of Qi and Blood
Postnatal depression may indicate Blood Deficiency has lead to Heart Blood
Deficiency