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Govt ayurvedic college patiala history sheets
1.
GOVT AYURVEDIC COLLEGE,
PATIALA DEPARTMENT OF ROGA NIDAN-VIKRUTI VIGYAN Case no: Name: IPD No: Date: Age: Gender: M/F Address: Religion:H/M/S/Cri/Oth. Educational Status:Il/P/S/Hsc/G/Tech. Occupation:Officework/Labor/Sedentary/other(ifany) FinancialStatus:P/M/UM/Rich. Marital Status:M/UM/W/D Chief Complaints (with duration): History of Present illness: Past History:
2.
If patient is
taking any specific medicine Family History (if any specific): 1. Personal History: 1. Diet(variety of food): Diet type–Vegetarian/Mixed Breakfast‐ Lunch‐ Snacks Dinner 2. Addiction: tea/coffee/tobaccochewing/smoking/alcohol/other Quantity /day Duration Yrs. 3. Appetite: Poor/Medium/excessive 4. Sleep: sound/Disturbed/withcontinuousdreams/insomnia 5. Urination: frequency /day /Night, Asso. Symptoms: painful/ burning/ excessive/ incontinence/ suppression 6. Defecation: regular/irregular,satisfactory/non satisfactory,hard/ semi solid/sticky
3.
Asso.Symp.:painful/burning/with blood/with mucus/suppression 7.
Flatus: normal/with sound/bad smell/suppression 8. Menstruation: regular/irregular,painful/painless/heavy/moderate/ scanty 10. Delivery /Abortion/Miscarriage 11. Emotional makeup: Prakrita/Utsahita/Udrikta/Khinna/Avasadita/ Bhavanatmaka /Bhawaheena Samanya Pariksha (General Examination) Nadi Pariksha: Jihva: Netra: Tvacha: Mala: mootra: B.P.: Pulse: Temperature: Respiration: Atura Bala Pariksha(Assessment of Patient strength) 1. Prakriti(Constitution)Vatta/Pitta/Kaphaja/VattPitt/PittKapha/Va ttKapha/Sama 2. Sara(Excellence Of tissues)–Pravara/Madhyama/Avara 3. Samhanana(Physique)‐Pravara/Madhyama/Avara 4. Pramana: Ht. cm,Wt. Kg..BMI: kg/m2 5. Satmya–Pravara/Madhyama/Avara 6. Satva: Pravara/Madhyama/Avara 7. Aaharsakti:Vishama/Sama/Manda / Tikshna 8. Vyayamasakti/Bala(Strength) – 9. Vaya(Age) –Balyavashtha/Yuvavastha/Vriddhavastha
4.
SYSTEM EXAMINATION 1. GASTROINTESTINAL
TRACT 2. RESPIRATORY TRACT 3. MUSCULOSKELETAL SYSTEM 4. NERVOUS SYSTEM
5.
5. URINARY SYSTEM 6.
.CARDIOVASCULAR SYSTEM 7. OTHERS
6.
7.
8.
9.
10.
11.
12.
LABORATORY INVESTIGATIONS BLOOD HB TLC
DLC ESR SEROLOGY BIOCHEMISTRY URINE ROUTINE: MICROSCOPE: STOOL:
13.
X-RAY: USG: OTHERS: Provisional diagnosis:‐
Differential Diagnosis:‐ Final Diagnosis:‐ Student’s Signature Teacher's Signature
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