DEPARTMENT OF KAYACHIKITSA

( Long Case )

OPD No: IPD No: BED No:

Patient’s Name:
Age/Sex: Religion: Desha: Season:
DOB: Education: Occupation: Marital status:
Address:
DOE: DOA: DOD:
Provitional Diagnosis:
Final Diagnosis:

Chief complaints with duration:

History of Present illness:

History of Past illness:

History of Past & Present medicine:

(Ayuvedic, Modern, Homeo others)

History of Blood transfusion:

History of Past Surgery

Family History:

1. Maternal History:
2. Paternal History:
3. Self-family Personal History:

General Examination:

1. Temperature 2. Respiratory rate 3. Blood pressure

Shadang Pariksha:

Shiro-griva
Hairs Nose Palate
Scalp Face Tonsils
Forehead Lips Thyroid
Eyes Teeth Neck
Ears Tongue

Antardi
Examination of: Inspection palpation Percussion Auscultation
Ura / Chest

Examination of: Inspection palpation Percussion Auscultation

Udar / Abdomen

Shakha
Upper extremities: Right - Left –

Lower extremities: Right - Left –

Shadvidhapariksha: Examination of Gyanendriya & Karmendriya

Gyanendriya Karmendriya

Shtrotraendriya Vak
Sparshanendriya Pani
Chakshunendriya Pad
Rasanendriya Payu
Ghranendriya Upastha
Ashtavidha-Pariksha:

Nadi: Gati: Rate/min: Dosha:

Mutra: Quantity: Colour: Frequency:

Mala: Quantity: Colur: Frequency:

Consistency:

Jivha: Colour: Nature:

Shabda: Nature of Voice:

Sparsha: Nature:

Drika: Colour of Eyes: Nature: Eyesight:

Akriti:

Dashvidha-Pariksha:

1. Prakriti- Sharira
Manas

2. Vikriti Pariksha:

3. Sara:

4. Samhanan:

5. Praman:

6. Satmya:

7. Satva:

8. Aaharshakti:

9. Vyayamshakti:

10. Vaya:

Rugna Bala: Pravar / Madhya / Avar Vyadhi Bala: Pravar / Madhya / Avar
 Examination of strotas
Strotas Darshan Sparshan Pariksha
1. Pranvaha

2. Udakvaha

3. Annavaha

4. Rasavaha

5. Raktavaha

6. Mamsavaha

7. Medovaha

8. Ashtivaha

9. Majjavaha

10. Shukravaha

11. Aartavvaha

12. Manovaha

13. Mutravaha

14. Purishavaha

15. Swedavaha
Examination of Vikruta Strotas

Strotas Dushti Hetu Dushti Lakshan

Other Examinations:

Examination of Ojovikriti :

Ojovyapad

Ojovistrance

Ojokshya

Nidanpanchak:
1. Hetu
2. Purvaroopa
3. Rupa:
4. Upshaya & Anupshaya
5. Samprapti

Shatkriyakala (Dosha/kala/Chaya/Prakop/Prasar/Sthan/samshray/VvaktiBhed)
Vata

Pitta

Kapha
Sampraptighatak :

Dushya Srotodusti Upadrava

Mala Agni Udarka

Udhabhavsthana Vyadhiavastha Sadhyasadhyata

Vyaktisthana Vyadhimarga Arishta Lakshana

Provisional Diagnosis:

Investigations:

Differential Diagnosis:

Final Diagnosis

Chikitsa Sutra

Shaman Chikitsa
Shodhan Chikitsa:

Pathya:

Apathya:

Follow-up
Sr. No. Date Particulars

Signature of student Signature of Teacher