Institute of Indigenous Medicine

University of Colombo
DEPARTMENT OF KĀYA CHIKITSA
ĀTURA PARIKSHA PATHRAYA – BAMS Level IV/V

1. Name of the patient:

Age:
Address:
Gender:
Religion:
Race:
Civil status:
Date of Admission:
Ward No:
Bed No:

2. Mukya peeda (Chief complaints with duration):

………………………………………………………………………………………………
………………………………………………………………………………………………
2.1. Anya peeda (Other complaints with time duration):
………………………………………………………………………………………………
………………………………………………………………………………………………
3. Athanka samutpatti karma (History of Present Complaint):
………………………………………………………………………………………………
………………………………………………………………………………………………
4. Chikitsa vritta (Treatment History):
………………………………………………………………………………………………
..……………………………………………………………………………………………..
5. Purva vyadhi vritta (Past Illnesses):
………………………………………………………………………………………………
………………………………………………………………………………………………
6. Pratyatma niyata vritta (Personal history):
6.1. Ahára/Diet: ………………………………………………………………………………...
6.2. Nidrá/Sleep: ………………………………………………………………………………..
6.3. Vyayama/Exercises: ……………………………………………………………………….
6.4. Habits and addictions: ……………………………………………………………………..
6.5. Occupation: ………………………………………………………………………………..
6.6. Educational status: …………………………………………………………………………

7. Matrial status & sexual behavior: ……………………………………………………………

7.1. Maternal history:
7.2. Paternal history:

8. Kula Pravritti (Family history):

9. Pariksha (Examinations)
9.1. Prakriti (Constitution)
A Sharirika (Physical):
B Manasika (Mental):
9.2. Vikriti Pariksha (Pathology)
A. Lakshana (Symptoms):
B. Abhipraya (Perspective):

10. Examination on Srotas

10.1. Pranavaha Srothas:

• Kása (Cough):
• Kanta (Throat):
• Uras bhága (Thorax):
• Puppusa (Lungs):
• Uchchása nishvása vega (Respiratory Rate):
• Nishteevana (Expectorant):
• Shirasa (Head):
 • Gnanendriya
• Karmendriya
• Manas

10.2. Udakavaha Srothas:

• Thálu (Palate):
• Udaka sanchaya (Oedema/Fluid retention):
10.3. Annavaha Srotas:

• Mukha (Mouth):
• Udara (Abdomen):
• Pakváshaya (Lower abdomen):
• Unduka (Appendix):
• Grahani (Duodenum):
• Kshudrantra (Intestine):
• Agni Ahára shakti
Jarana shakti
10.4. Rasavaha Srothas:

• Hrid (Heart):
• Lasika granti (Lymph nodes):
• Deha úshma (Body Temperature):
10.5. Raktavaha Srothas:

• Nadi/Pulse Gathi (Rate):

Yathi (Rythem):
Akriti (Volume):
Samhathi (Character):
Doshik predominance:

• Raktha sammarda/Blood Pressure:

• Dhamani (Artery):
• Sirá (Veins):
• Yakrut (Liver):
• Pleehá (Spleen):
• Raktha (Blood):
• Ojas Lakshana:

10.6' Mánsavaha/Medasvaha Srothas:

• Mánsapeshi (Muscles):
• Medas (Adipose tissues):
• Shareera bhára (Body weight):
10.7' Asthivaha/Majjavaha Srothas:

• Asthi (Bones):
• Sandhi (Joints):
• Késha (Hair):
• Nakha (Nails):
• Akshi sneha:
• Vit sneha:
• Thvak sneha:

10.8. Shukravaha/Ārthavavaha Srothas:

• Mushka (Penis):
• Medra (Testis):
• Shukra (Seminal fluid):
• Sthana (Breast):
• Sthanya (Breast milk):
• Garbáshaya (Uterus):
• Ārthava váhini (Fallopain tubes):
• Pala kósha (Ovary):
• Yóni (Vagina):
• Rajah pravrutti (Menstruation):

10.9. Purishavaha Srothas:

• Purishásya (Rectum):
• Gudha (Anus):
• Purisha (Faeces):

10.10. Mútravaha Srothas:

• Vasti (Bladder):
• Mútra márga (Urethra):
• Mútra (Urine):

10.11. Swedavaha Srothas:

• Thwak (Skin):
• Lóma (Body hair):
• Sweda (Sweat):

10.12. Manovaha Srothas:

• Buddhi Vipulata:
• Sathi:
• Bháshana (Speech):
 • Smruti (Memory):
• Vignana:
• Buddhi (Intelligence):
• Manó vibrama:

10.13. Gati Kriya (Motor function):

• Shakthi/Power:
• Thánya/Tone:
• Kampana/Tremour:
• Drudatha/Spasticity:

10.14. Gandhana Kriya (Sensory):

• Sparsha/Touch:
• Shoola/Pain:
• Peedana/Pressure:
• Thápa/Temperature:

11. Sára Pariksha

• Rasa:
• Raktha:
• Mámsa:
• Medas:
• Asthi:
• Majja:
• Shukra:
• Sattva:

12. Roga Vinishchaya (Diagnose)

12.1. Sápeksha Vinishchaya (Relative Diagnose):

12.2. Vividha Roga Vinirnaya (Differential Diagnose):

12.3. Roga Vinishchaya (Diagnose):

13. Samprapti (Pathogenesis)

13.1. Dosha:

Kevala/Nánátmaja:

Anubandha/Sámanyaja:

13.2. Dúshya:

13.3. Vitiated Srotas:

13.4. Sróto Dushti:

13.5. Vaikruta pariksha (Investigation):

14. Sádya Asádyatha (Prognosis):

15. Chikitsa Adhikára (Treatment Regime)

15.1. Chikitsa Múladharma (Fundamentals of Treatment):

15.2. Múlika chikitsa (Basic treatment):

15.3. Avasthavochitha Chikitsa (Suitable treatment regime):

16. Pathya Apathya (Suitable & Unsuitable)

16.1 Pathya:

16.2 Apathya:

Student’s Name:

Signature:

Date: