Have you ever had a patient meander in all sorts of directions when discussing their health concerns? Have you ever gotten lost in the miasma of information? Have you ever gone over time in that first appointment? With a proper initial intake, we ask the right questions that allow the patient to express themselves properly – somatically, which leads us to a diagnosis we can use.

Memorize This Acronym

One of my clinical supervisors, Alexander Audette, taught me an acronym I have been using in my practice since 2007: CPAUPSEEM (see-pop-seam). When he first taught it to me, I found it difficult to pronounce, which is likely why I was tentative in using it. Why would I bother learning such a silly acronym when the student clinic had standard forms to follow?

It wasn't until I started my own practice, where I had the opportunity to create my own intake forms, that I hearkened back to those school days.

C stands for Chills, Fever and Body Aches: We're asking the patient if they are suffering from an external pathogenic factor.

P is for Perspiration, Cough, Asthma and Breathing Problems: This determines the function of the lungs (wei qi) and kidneys.

A is for Appetite and Digestion: Here we learn about the patient's digestive system above the belly button, which includes the spleen and stomach.

U stands for Urination and Defecation: The elimination systems are located next to and below the belly button, indicating the function of the large intestine, and bladder / kidneys.

P is for Pain: Here is where we find out if the patient is suffering from pain anywhere in their body, including headaches, lower back pain, and soreness or weakness in the knees. Asking specifically about the lower back and knees helps us determine, or support a tentative diagnose of, deficiency of the kidneys.

S is for Sleep: Asking the patient if they have problems falling asleep (heart), problems waking up at night (yin deficiency, blood deficiency, liver-fire or food stagnation are common culprits), or if they suffer from vivid dreams disturbing their sleep (liver-blood deficiency) all have value in our diagnosis.

The first E stands for Energy: not waking rested is blamed on deficiency of  the spleen, while not having stamina throughout the day has to do with deficiency of the kidneys.

The second E is for Emotional Well-Being: When we ask the patient how they are feeling, we often receive a subpar response, so asking how they want to feel can help them express themselves better.

Finally, M stands for Menstruation and Menopause: Asking about menses, if applicable, tells us the state of the heart, liver, spleen and kidneys, while any symptoms related to menopause help us diagnose kidney-yin deficiency.

Whole-Body Analysis

When we use this acronym, the health of every organ gets analyzed (plus, yin, yang, qi, blood, and body fluids are all reviewed):

• Lungs: chills, fever, body aches; perspiration; emotional well-being
• Heart: sleep; emotional well-being
• Spleen: appetite; urination, defecation, digestion; sleep; energy; emotional well-being
• Liver: menstruation, menopause, sex drive & function; emotional well-being
• Kidneys: pain; menstruation, menopause, sex drive & function; emotional well-being

An Acronym for the Follow-Up visit: CSEP

The follow-up appointment is just as important as the initial intake; however, we do not have the luxury of going through the entire intake process again. Our re-interview needs to have focus: on the chief concern, plus three other bodily systems in the event these have changed since the last treatment. Following in Alexander's footsteps, I created CSEP:

C stands for Chief Concern. This is simple. We ask our patient how their chief concern is. I highly recommend asking patients to describe in some kind of value how they are improving, as their reality is the barometer for our success. For example, if a patient is experiencing multiple headaches in a week, ask them how many during the initial intake and then how many during the follow-up.

This not only helps us practitioners determine if we are making a dent in their condition; it also helps those patients who have a tendency to think things that don't completely go away aren't getting better.

Percentages are also helpful, especially when it comes to pain. If 100 percent better is no pain and full mobility, ask the patient to rate where they're at. Size is another great way to determine if a treatment is working. Size can be applied to menstrual blood clotting or zones of pain to see if either is shrinking.

S is a review of Sleep, E is a review of Energy, and P is a review of Pain. These three systems are always morphing and changing, so it's a great idea to keep checking in with them.

The re-interview should take as little as 10-15 minutes, which leaves plenty of time until the top of the hour to get those modalities in.

Beginning, Middle and End

The beginning of a new-patient intake should begin by discussing their chief concern. The middle of this intake should involve thorough questioning using CPAUPSEEM. The end of the intake should involve looking at the tongue and checking the pulse. By having a clear path set out before us, it is harder for us to get derailed by non-diagnostic information, harder to go over time in an appointment, and easier to come up with a diagnosis we can use.

Click here for more information about Kenton Sefcik, RAc, Dipl. Ac., Dipl. TCM.