T.T.

D’S S V AYURVEDIC MEDICAL COLLEGE, TIRUPATHI

DEPARTMENT OF KAUMARA BHRITYAM
CASE SHEET
S. No. Bed No:
Name of The Patient: Age:
Father’s Name: Sex:
Address: Religion:
Date of Discharge: Date of Admission:
Roga Nidana: Caste:
(Diagnosis) Socio-Economic Status:
1. Provisional: Result:
2. Final:

1. Mukhya Vyatha And Kalam (Chief Complaint with Duration):

2. Anubandha Lakshanani (Associated Complaints):

3. Atankasamutpatti Kramam (History of Present Illness):

4. Poorva Vyadhi Vrittam (History of Past Illness):

Birth History:

a. Prenatal:

b. Natal:

c. Post-Natal:

5. Kulavritta (Family History):

6. Pratyatmaniya Vrittam (Personal History):

Diet – Micturition –

Appetite – Sleep –

Bowel – Addiction –

a. Vividha Samskara:

b. Developmental Mile Stones:

c. Immunization:

7. Atura Pariksha (General Examination):

B.P: Temperature:

Pulse: Heartrate:

a. Anthropometry:

Height: Weight:

Mid-Arm Circumference: Mid-Thigh Circumference:

Head Circumference: Chest Circumference:

b. Ashtasthana Pariksha:

Naadi: Sabdha:

Mala: Sparsha:

Mutra: Drik:

Jihva: Akruti:

c. Shadanga Pariksha (Systemic Examination):

i. Shirogreeva (Head and Neck):

Eye:
Tongue:
Ear:
Neck:
Nose:
Oral Cavity:
Hair& Scalp:
 ii. CNS System:

iii. Musculoskeletal System:

iv. Respiratory System:

v. Cardiovascular System:

vi. Udara (Abdomen):

vii. Skin Examination:

viii. Urdhva Shaka (Upper Extremities):

ix. Adho Shaka (Lower Extremities):

x. Urogenital System:
8. Provisional Diagnosis:

9. Differential Diagnosis:

10. Vishesha Pariksha (Laboratory Investigations):

11. Samprapthi Vimarsha (Pathogenesis):

a) Dosha Vimarsa:

b) Dushya Vimarsha:

c) Adhistana Vimarsha:

12. Roga Vinischaya (Final Diagnosis):

13. Sadhyasadhyatha:

14. Cikitsa Sutra:

Sodhana: Shamana:

15. Pathya – Apathya:

Signature of Student Signature of Professor/Asst. Professor