MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES,

NASHIK
(For Academic Year 2009-10 batch)

Scheme of Practicals for Final M.D. (Ayurved)

Subject –Rog Nidan Avum Vikriti Vigyan
Duration: - 2 Years
i) Long Cases (Each 3 cases per Strotas ) 40
(Proforma attached as Annexure ‘A’)
ii) Short Cases (Each 2 case per Strotas ) 26
(Proforma attached as Annexure ‘B’)
iii) Laboratory Practicals

1) Fundamental Principles of Laboratory Tests 1

2) Introduction to laboratory, Sterilization, glass wares, solution regents & 1
safety procedures.
3) Heamograme 10
4) Blood cells counting 15
a) WBC - 5
b) RBC - 5
c) platelets - 5
5) Hematocrit / Packed Cell Volume (PCV) 5
6) Erythrocyte Indices 15
a) MCV - 5
b) MCH - 5
c) MCHC - 5
7) Peripheral Blood Smear, Staining technique & differential leucocytes count 5
8) Introduction to rapid diagnostics of hematology – Auto analyzer 20
9) Screening test bleeding disorders 15
a) Bleeding Time (BT) - 5
b) Clotting Time (CT) - 5
c) Prothrombin Time (PT) - 5
10) Blood grouping - ABO system, Rh typing (Rhesus system) 10
11) Peripheral blood film examination in 20
a) Anemia - 5
b) Leukemia - 5
c) Malaria - 5
d) Filaria - 5
12) Bio-Chemistry Test 21
a) K.F.T. - 3
b) L.F.T. - 3
c) Protein - 3
d) G.T.T. - 3
e) Lipid Profile - 3
f) BSL Estimation - 3
g) Hb A1-C - 3
13) Examination of Body Cavity Fluid 5
a) CSF - 1
b) Ascitic Fluid - 1
c) Pleural Fluid - 1
d) Synovial Fluid - 1
e) Pericardial Fluid - 1
 14) Demonstration of Sero -immunological Investigations 12
a) R.A. Test - 2
b) A.S.O. titer test - 2
c) WIDAL - 2
d) H.I.V. - 2
e) HBs Ag, - 2
f) V.D.R.L. - 2
15) Urine Examination 15
a) Ayurveda Anusara Mutra Pareeksha (Taila Bindu Parikshan, - 5
Piplika Parisarpan Pariksha)
b) Physical, Chemical & Microscopic Examination of Urine - 10
16) Stool Examination 10
a) Ayurveda anusara pareeksha (Sama - Nirama) - 5
b) Physical, Chemical & Microscopic Examination of Stool - 5
17) Sputum Examination 10
a) Ayurveda Anusara Sthivana Pareeksha - 5
b) Physical, Chemical & Microscopic Examination of Sputum - 5
18) Semen Examination 2
19) Introduction to Histo Pathology 15
a) Method of Histo path slide preparation - 5
b) Observation of permanent HP slides - 10
20) Introduction to Bacteriology 10
a) Method of Staining – Prepare different five slides - 5
b) Culture and Sensitivity (any body fluid) - 5
21) Examination of Body Cavity Fluid 5
a) CSF - 1
b) Ascitic Fluid - 1
c) Pleural Fluid - 1
d) Synovial Fluid - 1
e) Pericardial Fluid - 1
22) Aspiration Techniques 5
23) Gastric Analysis 2
iv) Introduction to advance diagnostic instruments with technique 8
a) ECG Machine - 1
b) USG Machine - 1
c) X-ray Machine - 1
d) Endoscope - 1
e) CT Scan - 1
f) MRI Scan - 1
g) E.E.G. - 1
h) Nuclear Scan - 1
v) Academic Visits (brief report should be written in Journal) 5
a) Visit to Blood Bank - 1
b) Visit to Serum Institute Pune / Haffkin Institute, Mumbai etc. - 1
c) ART Center - 1
d) Chemotherapy Centre - 1
e) Isolation Hospital - 1
vi) Social Activities 2
a) Blood Donation Camp (Min. 5) - 1
b) Participation in various diagnostics camps (Min. 10) - 1
 Annexure ‘A’

PROFORMA
LONG CASE PAPER

Name of Institute : _____________________________________________________________

Name of patient : _______________________ Age : _____________ yrs.
Address up to : _______________________ Sex : Male/ Female
Desha : Jangal / Anoopa/ Sadharana
police Station _______________________
Jataha Samvriddha Vyadhita
________________________________________
Religion : H/M./ S/ Ch/ J O.P.D. No. : __________________________
Marital Status : M/ UM/ D/ W I.P.D. No. : __________________________
Education : Un/ E/ P/ M/ HS/ G/ P/ Ward/ Bed No. : _______________________
Occupation : _____________________________ D.O.A. : _____________________________
Socio-eco. Status : VP/ LM/ M/ UM/ R Diagnosis : ___________________________

PRADHAANA VEDANAA (Chief Complaints with duration):

CHIEF COMPLAINTS DURATION

1) 7
2)
3)
4)
5)

II) VEDANA SAMUCCHRAYA & UPASAYA/ANUPASHAYA:

(History of Present Illness) & (Treatment taken & course of disease)
III) POORVA VYAADHI VRITTA:
(History of Past Illness/Associated complaints with treatment & results)
IV) FAMILY HISTORY OF DISEASES HAVING GENETIC REDISPOSITION :
(Prameha/ Kushtha/ Arsha/ Sthaulya etc.)
V) VAIYAKTIKA ITIBRITTA: (Personal History)
1. AAHARAJA:
a) Type of Diet : Vegetarian/ Mix / Dominancy of Dravya......

b) Dominance of Rasa in Diet : M / A / L / Kt / T / Ks

c) Dominant Guna in Diet : G / L / St / U / Sn / R / others

d) Dietary habits : Samasana / Adhyasana / Vishamaasana /

Pranitaashana Regular / Irregular / Viruddhahar-
e) Supplementary Diets : Tea / Coffee / Cold / drinks / others
f) Quantity : ______________________________
g) Vyasana (Habit) : Tobacco (Smoking/Chewing)/Alcohol/Sedative/Other
h) Quantity : Frequency __________Duration ________________
 2. VIHAARAJA:
a) Vyaayaama : Regularly / Irregularly / No / Less / roper / Excess

b) Vishraama (Rest) : _______________ hrs. / day ; _______________hrs. / night

c) Abhyanga : Yes / No

d) Snaana : Daily / Irregular

e) Nidraa : Samyaka / Asamyaks; Alpa /Prabhuta / Khandita

_______________hrs. / day ; __________ _____hrs. /
night

3. KOSHTHA – BOWEL:
a) Mridu / Madhya / Krura
b) Consistency (Samhanana): Kathina / Drava / Alpa Samhata /Susamahata
Sakastam/ Muhurmuhuh/ Sapravahana / Parikarthika / Sashabdha /Sashula
c) Frequency: ______________________time / day

4. MOOTRA PRAVRITTI- MICTURITTON:

a) Mootra Pravriti : Samyaka / krucchra / Vaivarnya / Daaha /Alpa / Prabhuta

b) Fequency : _______________Times /day _______________hrs. / night

c) App. quantity : _________________________ ml / 24 hrs .

5. ARTAVA PRAVRITTI-MENSTRUAL HISTORY:

a) Age of menarche :
________________________________________________
b) Age of menopause :
________________________________________________
c) Duration of flow :
________________________________________________
d) Duration of cycle :
________________________________________________
e) Nature : Regular/Irregular/Painful/Painless/Heavy/Scanty/Moderate

VI) AATURABALA (DEHA BALA) PARIKSHAA:

1) Prakriti :
a) Shaarira : V / P / K / VP / VK / PK / VPK )
b) Maanashika : S/R/T
2) Saara :P/M/A
3) Samhanana :P/M/A
4) Pramaana BMI : Height _________________cms. Weight ____________kgs
 P/M/A
5) Satva :P/M/A
Satva(Emot-make-up) : Prakrita/Utsahita/Udrikta/Khinna/Avasadita/Bhavanatmaka/
Bhavaheena
6) Saatmya :P/M/A
7) Vyaayaama Shakti :P/M/A
8) Agni Pareeksha :P/M/A

VII) HETU (INDAANATAH) PARIKSHA

DOSHA DOOSHYA / SROTO AGNI KHA-
NIDANA
PRAKOPAKA DUSHTIKARA MANDYAKARA VAIGUNYAKARA
Ahara
Vihara
Manasika
Vyadhi
Vishesha

VIII) ROGA BALA PARIKSHAA :

__________________________________________
KAPHAVARGA PARIKSHAA : __________________________________________
KAPAHADOSHA PARIKASHA

PAPEEKHA
VRIDDHI KSHAYA PRAKOPA
BHAAVA
Sweta- Twachaa, Mala- Shvetataa- Msla, Mootra,
Rukshyataa / Sandhi
Darshana Mootra /Sndhi Vishlesa / Twak / Utsedha / Sneha
shaithilya
Swaasa / Kaasa Upachaya
Sparshana Shaitya / Sthairya Kleda /Shaitya
Trushnaa / Nidraa Naasha /
Gourava / Avasaada / Dourbalya / Antardaaha / Kandu / Sthairya /
Tandraa / Aslasya, Hriddrava / Bhrama Gourava / Upalepa /
Prashna
Agnisaada, praseka / /Aamaashyetara Shlema- Alasya / Kleebata /
Snadhivishlesha aasaya Shunyataa / Utsaha
Shirasasa cha Sunyataa
1) RASA & RASAVAHA SROTASA PARIKSHAA:
PAREEKSHYA
VATA PITTA KAPHA
BHAVA
Krishnaangataa/ Rujshata Sveda / Paandutwa / Vaivarnya / Pandu /
Darshana
/ Sosha Akale – vali – Palita Shvetataa
Sparshana Loss of densation Jwara Shaitya
Alpa Kandu / Mukha
Angamard / Klaibya / virasataa / Gurataa /
Asyavairasya / Tandraa Aslasya /
Arasajnataa / angamarda Utklesha / Hrillaasa /
/Hrit – Kampa / Hrit Drava Aruchi / praseka
Prashna Tama
/ Hritpiadaa / Hritsunyataa/ /Vamana Anna Dvesha
trishnaa /Hrit Ghattana / Agni Mandya /
Sabda- asahishautaa / Asraddhaa / Aruchi /
hritshoola / Sramah Hrillaasa / Srotorodha /
Saada / Hridayotkleda
Temperature
Blood Pressure
Nadi – Pulse
(Palpation
Percussion
Auscultation)
1) Hridaya
Dhamani
2) Twak,
Inspection Palpation Percussion Auscultation
3) Lasika,
Granthi,
4) Rasa –
Rakta
Samvahana
ECG,X-Ray,
USG
Biochemical
investigations
2) MAMSA & MAMASVAHA SROTASA PARIKSHAA:
PAREEKSHYA
VATA PITTA KAPHA
BHAAVA
Suskataa- (Sphik- Ganda Vriddhi – Sphik – Ganda –
– Ostha – Upastha – Uru Putimaamsa / Ostha – Upastha –Uru-
Darahana
– Vakshya – kakshyaa – Alaji Baahu – Janaghaa /
Pindika – udara – Grivaa) Adhimaamsa / Arbuda
Roukshya / Dhamani
Sparshana
Shaithilya
prashna Toda / Gaatra / Sadana Guru Gaatrataa
khamala
Aandara and Vasa
Avayava Pareeksha
Snayu, Kadara,
Peshi, Twak
Bio-chemical
S.Creatinine, CPK

3) MEDA & MEDOVAHA SROTAS PARIKSHAA :

PAREEJSHYA
VATA PITTA KAPHA
BHAAVA
Snigdhaangataa / Udara
Vriddhi / Paarshwa Vriddhi/
Atidiraha /
Atigoura/ Atisthoola / Jatili
Atihraswa
Darshana alomaa Bhaavakeseshu/Chhidreshu
/Atilomaa /
Upadeham / Gaatre
Atikrishna
Pippilikaa Saranama Mutre
Pippilikaa Sranam
Sparshana Plihaa Vriddhi
Kara – Paada
Prashna Dourganadhya/ Daaha/ Kaasa / Swaasa
Supatataa/
Mukhasosha / Taalusosha/ Maadhuryamaasye / aslasya
Anga Supatataa Kanthasosha / Pipaashaa / / Nalakaaye Mutradosha /
Pridaaha / Vishragandha Nidraa / Tandraa
Lipid profile BMI /
Body Wt.
Vapavahana,
Ganda, Sphika,
Kati, Vrikka.
ECG, X- Ray, USG
4) MAJJA & MAJAAVAHA SROTAS PARIJSHAA :
PAREEJSHYA
VATA PITTA KAPHA
BHAAVA
Parvasu Sthoola mulaani
Darshana Arunsi Janma /
Netraabhisyanda
Sparshana Asthi Soushiryaata
Parvaruk /Alpa Sukrataa
/ ParVa Bheda / Asthi
Murchchhaa /
Nistoda / Asthi Sunyataa Sarvaanga Gourava /
Prashna Tamodarshana/
/ Asthi dourvalya/ Asthi Netra Gourava
Bhrama
Laaghava / pratata Vaata
Rogami
Twak Sneha
Bone Marrow
Sandhi. Pleeha
ECG. X –Ray USG
MRI
5) SHUKRA & SUKARAVAHA SROTASA PARIJSHAA :
PAREEJSHYA
VATA PITTA KAPHA
BHAAVA
Darshana Virupam Paandutwm/ Sukrameha
Sparshana
Klaibya / Aharshanam/
Roginam Alpaayu / Dourbalya
Prashna
/ Mukhasosha Sadana /
Shrama / Sukra Avisarga
STANA & STANYA
Pariksha
Artava & Artava Vaha
Sroto – Pariksha
Female Reproductive
organs
Semen Examination
Examination of
Reproductive organs
Vrishana / Shephas
Testicular biopsy
OJAS :
PAREEJSHYA
VATA PITTA KAPHA
BHAAVA
Oja Visramsa Srama /Sandhi Vislesha Gatra Sadana
Oja Vyapat Stabdhata Gutu-Gatrata, Tandra, Nidra
Mamsa etc. Dhatujsaya /
Ojakshaya
Moha / Pralapa / Agyan

6) UDAKAVAHA SROTASA PARIJSHAA :

PAREEJSHYA
VATA PITTA KAPHA
BHAAVA
Jihwaa-Taalu – Outha –
Darshana
Kantha- Kloma- Shosha
Prashna Ati Trishnaa
Sparshana
Talu, Jihva,
Netra, Twak
especially for
hydration
purpose
7) PRAANAVAHA SROTASA PARIKSHA :
PAREEJSHYA
VATA PITTA KAPHA
BHAAVA
Uchchhwaasa-
Uchchhwaasam-
Darshana Atisristam, Kupitm,
Alpamalpam,
Abhikshana,
Sparshana
Sashabdam,
Prashna Atibaddham
Sashoolam
Shvasa Praikshana
Stheevana Pariksha
Inspection Palpation Percussion
Respiratory System
Auscultation
Pulm, Function test
PITTA VARGA PARIKSHAA:
PIITA DOSHA PARIKSHA:
VATA PITTA KAPHA
Darshana Pitaababhaasataa / pita Nisprabhataa Paaka / Sweda / Kleda
(Vid-Nutra-Netra-Teak)/ / Kotha/ Sraava /
Nurchchhaa Raaga / Murchchhaa
Sparshana Samtaapa Mandoshmataa Oushnya,
Prashna Sitakaamitwa / Mandaagni Daaha / Knadu / Vishra
Alpanidrataa / Valahaani / Gandha / Sadana /
Indriyadourvalya Mada /Katukaasyataa/
Amlaasyataa

8) RAKTAVAHA SROTAS PARIKSHAA:

PAREEJSHYA
VATA PITTA KAPHA
BHAAVA
Raktakshaya /Rukshata / Raktapitta/ Upakusha /
Gulma / Vatashonita / Asyapaka / Raktanetrata
Vaivarnya /Ati-daurbalya / / Rajtmandal / Kitha / Pidaka / Kustha
Darshana kampa / Carmadala / Mukhapaka / Visarpa / / Kustha / Masaka
Pramilaka / mlana /Twak Midradhi / Raktameha / /Arbuda / Dadru /
Roukshya Vaivarnya / Sweda /
Indralupta / Raktaanga
Sira – shaithilya/ Twak Siraapurnatwan,
Sparshana Sira- Poorantva
Paarushya Santaapa
Raktapitta /Murcchaa .
Pootighrana / Agninandaya /
Prashna Amlashishira –parthana / Asyagandhita/ Guragatrata / Aruchi /
Swarakshya, Mada Annapansya Vida / klama / Lavanasyata /
Sweda / Shria – kandu
Dugandiya . Jara
Haematology
T.L.C
D.L.C
TR.B.c.
Hb%
MCV/ VCH .
MCHC
E.S.R
BT/ CT / PT
Yakrita.
Pleeha,
Sira
USG /MRI/
LET
SWEDAVAHA SROTAS PARISHAA :
PAREEKHYA
VATA PITTA KAPHA
BHAAVA
Aswedana / Swedanaasa /
Darshana Romachyuti / Twak Atisewdana
S[hutana
Paarushya / Sparsha
Sparshana Slakshnangataa
Vaigunya
Paridaaha /Twak
Prashna Lomaharsha / Ksdu
Durandhya
Twak / Roma

ANNAVAHA SROTASA PARIKSHAA :

PAREEKHYA
VATA PITTA KAPHA
BHAAVA
Darshana Aadhmaana
Sparshana
Anannaabhilashanam /
Pipaasaa / Amla- Arochakam / Avipaaka /
Prashna Shooloa / Ati-Udgara
Katu-Ugara Annawwsha / Chhardi /
Nadhura udgara
Ruchi Arasagyata Amla / Tikta Asyata Aruchi / Madhurasyata
Abhyavaharana
Vishma Kshudha Atikshudha Anannabhilasha
Shakti
Jarana Shakti Vishama Vidaha Aam- Ajeerna
Examination of GIT, Inspection Palpation Percussion
Gall Bladder Auscultation
X- Ray/ USG
Free acid / Total HCL
Examination

MOOTRA & MOOTRAVAHA SROTAS PARIKSHAA:

PAREEKHYA VATA PITTA KAPHA
BHAAVA
Aadhmaana /
Darshana
Mutravaivanya
Sparshana
Alpa Pravritti / Bahala Mutra /
alpamutataa / Sashula prabhhut mutrata /
Sadaha – Atisrista
Prashna Pravritti / Bastitoda / Atibddha Pravritti /
Pravritti
Mutrakrichchhrata / Kandu /
Pipaasaa
Mootra Pariksha
Physical, Chemical &
Arasagyata Amla / Tikta Asyata Aruchi / Madhurasyata
Microscopic Culture
examination
Examination Inspection palpation
Jarana Shakti Vishama Vidaha Aam- Ajeerna
X- Ray/ USG
RFT
VAATA VARGA PARIKSHAA
VATA STHANA PARIKSHA :
VATA PITTA KAPHA
Alpa Chestataa /
Alpa Vaaktwam/
Kaarshya / krishnataa .
Mudha Sjnataa / khanja / Pangu / Kubjatwa /
Darshana Gaadha Varcastwam/
Uchchhwaasa Angasosha / Aakshepa
Amaaha
Niswaasa
Mandataa
Sparshana Twak Paarushya Gaatrasuptataa
Sankocha / Parvastambha /
Asthibheda / Pravabheda /
Vaakpaarushyam / Anidra / Naasha Garbha –
Gaatrasphurana / Ushana Apraiharsha / Sukra – Raja / Spandanam-
Kaamitaa / Nidraa Naasa / Utsaaha Haani / Hundana- Sira (Naasaa- Akshi
Prashna Alpabalatwa / Sakritgraha Manda PravRitti – – Jatru - Grivaa)-
/ Indriya Bhramsha / Sweda – Mutra Bheda+Toda / Ari / Moha /
Dainya Praalaapa / Purisha Asyaasa / Manovyaaharsana/
Gaadha Varchastwann Indriya Upahanana / Bhaya /
Shoka / Graha (Paani. Pristha
Sira) Pralaapa / Lomaharsha

ASTHI & ASTHIVAHA SROTAS PARIKSHAA :

PAREEKHYA
VATA PITTA KAPHA
BHAAVA
Darshana
Sparshana
Aatopa / Adhovata Snga /
Adhovata Ati Pravritti / Kukhishoola
/ Sakrits Vedanaa / Hritpidaa /
Prashna Paarwapida / Ssabda Vaatasya Gourava
Urdhwagamana / Asdhmaana /
Aantrapidana / Kukshinamana /
Vaayoh Tiryagurdhya Gamana
Purisha Pariksha
Consistency
(Samhanana)-
Varna Kathina / Roukshya Krishna / Sashleshma
Drava peeta, Rakta
(Colauration)- Aruna Prakrutha / Vikrutha Shveta
Gandha (Odour)-
Saama /
Miraama
Stool
Examination
Examination of
Large Intestine.
Rectum, Anus,
(P/R)
X Ray – BARIUM
ENEMA USG.
COLONOSCOPY
SANGYAVAHA , MANOVAHA , CHETANA VAHI STOTASA :
PAREEKHYA
BHAAVA DARSHANA.
VATA PITTA KAPHA
SPARSHANA PRASHNA
(ANUMANA)
Karmendriya Pariksha
GYANENDRIYA PARIKSHA
karan-
Nasa-
Netra-
Jihav-
Tvacha-
Manas Karma Pariksha
Buddhi Pariksha
Nervous System Examination
CNS. Motor & Sensory
EEG, MRI, CT Scan. Verve
conduction test

ROGA PARIKSHA :
SAMPRAPTHI GHATAKA
1) DOSHA: _____________________________________________________________
i) Prithaka (with or without type)
VATA PITTA KAPHA
PR/ UD / SM / VN / AP PC / RJ / BH / SD / AL KL / AV / BD / TR/ SH

ii) Sansarga : Vata – Pitta / Vata – Kapha / Pitta – Kapha

ii) Sannipata : Vata- Pitta- Kapha

iii) Avarana : _______________________________________________________

iv) Aashayaapakarsha: ______________________________________________

2) DOOSHYA :-
Dhatu : Rasa / Pakta / Mansa / Meda / Asthi / Majja / Shukra
Upadhatu : Stanya / Raja / Kandara / Sira / Dhamani / Twacha / Snau
Mala : Poorisha / Mootra / Sweda / Kapha / Pitta / Khamala / Kesha / Nakha /
Akshisneha Loma / Shmashru
3) Srotasa : Dosha Vruddhi Dushya Vruddhi /Kshaya Sroto Dusti Prakara

4) AGNI : Sama / Vishama / Tikshna / Manda

5) UDBHAVASTHANA : Ama / Pakwa

6) ADHISHTHANA Ama /Pakwa

7) VYAKTISTHANA: ______________________________________________________

8) KRIYAKALA: __________________________________________________________

9) ROGAMARGA: Koshtha/ Shakha / Marma

10) VYADHI SWARUPA : Chirakaari / Aasukaari Mruda / Daaruna Naveena / Jeerna

NIDAANA :
______________________________________________________ ROORVARUPA
: ______________________________________________________
ROOPA :
______________________________________________________
UPASHAYA : ______________________________________________________
ANUPASHAYA :
______________________________________________________
SAMPRAAPTI CHAKRA :
______________________________________________________
SAMBHAVITHA VYADHI :
______________________________________________________
VIBHEDAKA/ VYAVACCHEDA NIDANA : ________________________________________
ROGAVINISCHAYA : ______________________________________________________
VYADHI AVASTHA : Saama / Niraama Utthana / Gambhira
SAADHYAASAADHYATAA:sadhya /Krichchhrasaadhya/yaapya/pratyaakheya
UPADRAVE : ______________________________________________________
ARISHTA LAKSHANAS (IF ANY): ______________________________________________
AYUSHAHA PRAMANA PARIKSHAA : ___________________________________________
MANAGEMNT :
______________________________________________________
CHIKITSA SOOTRA : ______________________________________________________
a. Drug : ______________________________________________________

b. Dose & Anupana : ______________________________________________________

c. Pathya / Apathya : ______________________________________________________

d. Continue treatment up to
PANCHAKARMA
A) POORVA KARMA
a. Deepana / Pachana
b. Abhyantara Smehapana (Acccrding to Koshtha)
1st day .......................... / 2nd day ............................... / 3rd day ..............................
4th day ........................../ 5th day ................................../ 6th day
................................
c. Swedama (Next 3 days)
B) PRADHANA KARMA
i. Drug :
______________________________________________________
ii. Dose :
______________________________________________________
iii. No. of Vegas: ______________________________________________________
 iv. Shuddhi : Pravara / Madhyama / Avara

C) PASCHATA KARMA (SAMSARJANA KARMA):

1. Eka-annakala / Dwi-annakala / Tri-annakala
D) PARIHARAKALA : _____________________________________________________
E) SHMANA YOGA : _____________________________________________________
Dose : _____________________________________________________
Anupana : _____________________________________________________

Sign. of Student Sign. of Guide

Date :- Date :-
 Annexure ‘B’

PROFORMA
SHORT CASE PAPER

Name of Institute : _____________________________________________________________

Name of patient : _______________________ Age : _____________ yrs.
Address up to : _______________________ Sex : Male/ Female
Desha : Jangal / Anoopa/ Sadharana
police Station _______________________
Jataha Samvriddha Vyadhita
________________________________________
Religion : H/M./ S/ Ch/ J O.P.D. No. : __________________________
Marital Status : M/ UM/ D/ W I.P.D. No. : __________________________
Education : Un/ E/ P/ M/ HS/ G/ P/ Ward/ Bed No. : _______________________
Occupation : _____________________________ D.O.A. : _____________________________
Socio-eco. Status : VP/ LM/ M/ UM/ R Diagnosis : ___________________________

PRADHAANA VEDANAA (Chief Complaints with duration):

CHIEF COMPLAINTS DURATION
1)
2)
3)
4)
5)

II) VEDANA SAMUCCHRAYA & UPASAYA/ANUPASHAYA:

(History of Present Illness) & (Treatment taken & course of disease)
III) POORVA VYAADHI VRITTA:
(History of Past Illness/Associated complaints with treatment & results)
IV) FAMILY HITORY OF DISEASES HAVING GENETIC REDISPOSITION :
(Prameha/ Kushtha/ Arsha/ Sthaulya etc.)
IX) VAIYAKTIKA ITIBRITTA: (Personal History)
1. AAHARAJA :
Type of Diet : Vegetarian/ Mix / Dominancy of Dravya ......
Dominance of Rasa in Diet : M / A / L / Kt / T / Ks
Dominant Guna in Diet : G / L / St / U / Sn / R / others
Dietary habits : Samasana / Adhyasana / Vishamaasana /
Pranitaashana Regular / Irregular / Viruddhahar-
Supplementary Diets : Tea / Coffee / Cold / drinks / others
Quantity :
Vyasana (Habit) : Tobacco (Smoking / Chewing) / Alcohol / Sedative /
Other : __________________________________________
Quantity : Frequency _____________ Duration ___________

2. VIHAARAJA :
Vyaayaama : Regularly / Irregularly / No / Less / roper / Excess
 Vishraama (Rest) : hrs. / day ______________ hrs. / night
________________
Abhyanga : Yes / No
Snaana : Daily / Irregular
Nidraa : Samyaka / Asamyaks; Alpa /Prabhuta / Khandita
hrs. / day ________________ hrs. / night
_______________

3. KOSHTHA – BOWEL: Mridu / Madhya / Krura

Consistency : (Samhanana): Kathina / Drava / Alpa Samhata
/Susamahata
Sakastam/ Muhurmuhuh/ Sapravahana / Parikarthika /
Sashabdha /Sashula
Frequency : ________________________________________ time / day

4. MOOTRA PRAVRITTI- MICTURITTON:

Mootra Pravriti : Samyaka / krucchra / Vaivarnya / Daaha /Alpa / Prabhuta
Fequency : _______________ Times /day ______________ hrs. / night
App. quantity : _______________________________________ ml / 24 hrs

5. ARTAVA PRAVRITTI-MENSTRUAL HISTORY:

Age of menarche : ________________________________________________
Age of menopause : ________________________________________________
Duration of flow : ________________________________________________
Duration of cycle : ________________________________________________
Nature : Regular/Irregular/Painful/Painless/Heavy/Scanty/Moderate

X) AATURABALA (DEHA BALA) PARIKSHAA:

1) Prakriti :
a) Shaarira : V / P / K / VP / VK / PK / VPK )
b) Maanashika :S/R/T
2) Saara :P/M/A
3) Samhanana :P/M/A
4) Pramaana : Height ............... cms. Weight ............ kgs
BMI :P/M/A
5) Satva :P/M/A
Satva(Emot-make-up) : Prakrita/Utsahita/Udrikta/Khinna/Avasadita/Bhavanatmaka /
Bhavaheena
6) Saatmya :P/M/A
7) Vyaayaama Shakti :P/M/A
8) Agni Pareeksha :P/M/A
XI) HETU (INDAANATAH) PARIKSHA
NIDANA DOSHA DOOSHYA / SROTO AGNI KHA-
PRAKOPAKA DUSHTIKARA MANDYAKARA VAIGUNYAKARA
Ahara
Vihara
Manasika
Vyadhi
Vishesha

XII) ROGA BALA PARIKSHAA:

KAPHAVARGA PARIKSHAA:
KAPAHADOSHA PARIKASHA
PAPEEKHA
VRIDDHI KSHAYA PRAKOPA
BHAAVA
Sweta- Twachaa, Shvetataa- Msla,
Mala- Mootra /Sndhi Mootra, Twak /
Darshana Rukshyataa / Sandhi shaithilya
Vishlesa / Swaasa / Utsedha / Sneha
Kaasa Upachaya
Sparshana Shaitya / Sthairya Kleda /Shaitya
Trushnaa / Nidraa Naasha /
Gourava / Avasaada / Dourbalya / Antardaaha / Kandu / Sthairya /
Tandraa / Aslasya, Hriddrava / Bhrama Gourava / Upalepa /
Prashna
Agnisaada, praseka / /Aamaashyetara Shlema- Alasya / Kleebata /
Snadhivishlesha aasaya Shunyataa / Shirasasa Utsaha
cha Sunyataa

XIII) Pathological Investigations :-

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
__________________

ROGA PARIKSHA :
SAMPRAPTHI GHATAKA
1) DOSHA:-
i) Prithaka (with or without type)

VATA PITTA KAPHA

PR/ UD / SM / PC / RJ / BH / KL / AV / BD /
VN / AP SD / AL TR/ SH

ii) Sansarga : Vata – Pitta / Vata – Kapha / Pitta – Kapha

iii) Sannipata : Vata- Pitta- Kapha

iv) Avarana :
________________________________________________
v) Aashayaapakarsha :
________________________________________________
2) DOOSHYA :-
Dhatu : Rasa / Pakta / Mansa / Meda / Asthi / Majja / Shukra
 Upadhatu : Stanya / Raja / Kandara / Sira / Dhamani / Twacha /
Snau
Mala : Poorisha / Mootra / Sweda / Kapha / Pitta / Khamala / Kesha
/ Nakha / Akshisneha Loma / Shmashru /
3) Srotasa : Dosha Vruddhi Dushya Vruddhi/Kshaya Sroto Dusti Prakara

4) AGNI : Sama / Vishama / Tikshna / Manda

5) UDBHAVASTHANA : Ama / Pakwa

6) ADHISHTHANA : Ama /Pakwa

7) VYAKTISTHANA : ________________________________________________

8) KRIYAKALA : ________________________________________________

9) ROGAMARGA : Koshtha/ Shakha / Marma

10) VYADHI SWARUPA : Chirakaari / Aasukaari Mruda / Daaruna Naveena / Jeerna

NIDAANA :
________________________________________________
ROORVARUPA :
________________________________________________
ROOPA :
________________________________________________
UPASHAYA : ________________________________________________
ANUPASHAYA :
________________________________________________
SAMPRAAPTI CHAKRA :
________________________________________________
SAMBHAVITHA VYADHI :
________________________________________________
VIBHEDAKA/ VYAVACCHEDA NIDANA: _________________________________________
ROGAVINISCHAYA : ________________________________________________
VYADHI AVASTHA : Saama / Niraama Utthana / Gambhira
SAADHYAASAADHYATAA : sadhya /Krichchhrasaadhya/yaapya/pratyaakheya
UPADRAVE ; ________________________________________________
ARISHTA LAKSHANAS (IF ANY) : ______________________________________________
AYUSHAHA PRAMANA PARIKSHAA: ___________________________________________
MANAGEMNT
CHIKITSA SOOTRA : ________________________________________________
a) Drug : ________________________________________________

b) Dose & Anupana : ________________________________________________

c) Pathya / Apathya : ________________________________________________

d) Continue treatment up to: _______________________________________________

 PANCHAKARMA :
________________________________________________
A) POORVA KARMA
a) Deepana / Pachana : ______________________________________________

b) Abhyantara Smehapana (Acccrding to Koshtha)

1st day ......................... / 2nd day .............................. / 3rd day ..............................
4th day ........................../ 5th day ................................/ 6th .......................................
c) Swedama (Next 3 days)
B) PRADHANA KARMA
i) Drug : ________________________________________________

ii)Dose : ________________________________________________

iii)No. of Vegas : ________________________________________________

iv)Shuddhi : Pravara / Madhyama / Avara

C) PASCHATA KARMA (SAMSARJANA KARMA):
Eka-annakala / Dwi-annakala / Tri-annakala
D) PARIHARAKALA : ________________________________________________

E) SHMANA YOGA :
________________________________________________
Dose : ________________________________________________
Anupana : ________________________________________________

Sign. of Student Sign. of Guide

Date :- Date :-