TCM “ROOT DIAGNOSIS” QUESTIONNAIRE
Please check the box next to symptoms that you have experienced in the past month or tend to experience in general.
PART A
PART B
Shortness of breath
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Cold, wearing warmer clothes than others
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Weak voice
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Cold arms and legs or hands and feet
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Little or no desire to speak
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Preference for hot drinks
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Fatigue
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Wake up at night to urinate
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Low energy
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Frequent copious amounts of clear or pale urine
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Spontaneous sweating
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Dislike winter or air conditioned rooms
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Prefer quiet environments with less talking
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Discomfort after eating cold foods
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Dislike physical activity
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Symptoms are worse during cold weather
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Weakness or lack of strength
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Tip of the nose is cold
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Frequent, small amounts of pale urine
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Absence of thirst
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PART C
PART D
Feeling of heat in the afternoon
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Head spins when standing up
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Hands and feet get hot
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Numbness of hands and feet
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Heat in the center of the chest, near the heart
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Dry or brittle skin, hair or lips
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Dry, parched throat, especially at night
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Brittle or withered nails
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Restless, uneasy, fidgety, agitated
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Anxiety
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Cheeks and face get flushed
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Loss of balance
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Underweight
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PART E
Night sweats
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Bleeding of dark, clotted blood
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Hot flashes
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Bruises or bleeding under the skin
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Blood clots
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PART F
Profuse bleeding of any kind
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Black or very dark stools
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Urinate small amounts of dark urine
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Spider veins or other visible veins
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Hot-tempered
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PART G
Preference for cold drinks
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Heaviness of head or body
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Very thirsty
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Pain and heaviness in joints
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Bitter taste in the mouth all day
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Stickiness in the mouth
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Mouth sores
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Fatty bumps under the skin
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Hot, warmer than the people nearby
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Edema or swelling
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Halitosis, bad breath
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Bone growths or deformities
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Head gets sweaty
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Feel heavy, slow or sluggish
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Always hungry
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Runny nose or coughing up phlegm
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Foul smelling stools
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Bowel movements contain mucous
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Bleeding gums
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Cloudy urine
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Thirst with no desire to drink
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PART H
PART I
Sores on the tongue
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Symptoms that worsen with emotions
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Dream disturbed sleep
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Anger, frustration, bitterness
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Difficulty falling asleep, but sleep well
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Ribside pain
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Angina
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Frequent sighing
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Speech pathology (stutter, lisp, aphasia)
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Feel like a lump is stuck in the throat
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Hyperactivity, excitability
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Depression or mood swings
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Can’t think of the word you want to say
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Stressed out or irritable
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Bitter taste in the mouth in the morning
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Clumsiness
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Palpitations: heartbeat feels too fast
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Blurred vision or floaters in your eyes
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Constipation with bitty stools
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PART J
Cough
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Alternating constipation and diarrhea
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Sneeze
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Tinnitus, loud, high – pitch, like a whistle
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Struggling to breathe
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Dry eyes
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Unexplained sadness
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PART K
Asthma
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Abdominal bloating
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Catch colds easily
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Lack of appetite
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Swelling of the eyes and face
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Worry or excessive thinking
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Prolapsed organ (uterus, bladder, etc.)
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PART L
Diarrhea first thing in the morning
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Sweet taste in your mouth
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Brittle or loose teeth
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Watery stools
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Weak bones
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Feel sleepy after eating
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Incontinence of urine or stools
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Loose stools containing undigested food
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Sore or weak back or knees
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Hemorrhoids
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Difficulty inhaling a deep breath
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Poor digestion
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Premature graying or thinning of hair
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Nausea
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Hearing Impairment
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PART M
Salty taste in the mouth
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Dizziness
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Wake up many times during the night
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Constipation
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Tinnitus, low – pitch, like rushing water
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Bowel movements contain blood
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Thirsty, prefer small sips of liquids
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Painful urination
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Pressure in the eyes
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Wake early and can’t fall asleep again
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Difficult urination
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Seizures
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Patient Name __________________________________________________ Date ___________________