SNWS'S SGV Ayurvedic Medical College Hospital And Research Center Bailhongal

CASE PROFORMA

"cLrNrcAL EVALUATTON OF KARNASqHOTHA (CARD\OSqERMUM

HELTCACABUM LrrVrU' ROOT GELIN DARUNAT(A (DANDRUFF)"

Name:

Age/ Sex: OPD No:

Occupation: Date:

Address:

Chief complaints and duration:

History of present illness:

History of past illness:

Family history:

Occupational history:

Personal history:
A. Personal habits:
1. Appetite: 2.D ret:
3. Sleep: 4.8 owel:
5. Habits:
Treatment history:

GENERAL EXAMINATION:
a. Pulse c. B.P.
b. Temp: d. Respiratory rate:
 LOCAL EXAMINATION:
PADA:

DASHA}'IDHA PARIKSHA:
Prakruti
Vikruti
Sara

Sanhanana

Pramana
Satmya
Satva

Aharashakti
Vyayamashakti
Vaya

Investigations: NA

TREATMENT:

Topical application of Karnasphotha(Cardiosprmum Helicacabum) Root Gel on Scalp as hair

mask Twice a week before Head bath for 2 weeks.

FOLLOWUP CHART:
DAYS SYMPTOMS REMARKS
Kandu(ltching) Rookshata(Dryness) Twak Kesha chyuti(Hair
sphutana(Sc fall)
aling)

1't day

8tn day

15th

day
RESULT:

Full mitigation 75 -I00% relief

Si gnifi cant improvement 50-74o/o relief
Mild improvement 25 49Yo rclief
Unsatisfactory < 25Yo improvement fiom the pre-test
condition

Signature of the participant Date:

Signature of the investigator: &- Date: fi I r I 2.1-

Signature of the HOD : Date: U)fl l"r

Signature of the Principal :

PRI
Date: t4b'
S.N.V.V. msthe's
S,_G.V Ayurvedic Mer:i;.;.'. .i :,-'Ce Hospital &
Reseamh Cenlei. kJ,rtiir),\ J-A: .Sgii0Z