DEPARTMENT OF KAYACHIKITSA

( Short 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 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 Dushti Lakshan Dushti Hetu

Nidanpanchak:
1. Hetu

2. Purvaroopa

3. Rupa:

4. Upshaya & Anupshaya

5. Samprapti

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:

Signature of student Signature of Teacher