1.
GOVT AYURVEDIC COLLEGE, PATIALA
DEPARTMENT OF ROGA NIDAN-VIKRUTI VIGYAN
Case no:
Name: IPD No:
Date:
Age: Gender: M/F
Address:
Religion:H/M/S/Cri/Oth. Educational
Status:Il/P/S/Hsc/G/Tech.
Occupation:Officework/Labor/Sedentary/other(ifany)
FinancialStatus:P/M/UM/Rich. Marital
Status:M/UM/W/D
Chief Complaints (with duration):
History of Present illness:
Past History:

2.
If patient is taking any specific medicine
Family History (if any specific):
1. Personal History:
1. Diet(variety of food):
 Diet type–Vegetarian/Mixed
 Breakfast‐
 Lunch‐
 Snacks
 Dinner
2. Addiction:
tea/coffee/tobaccochewing/smoking/alcohol/other
Quantity /day Duration Yrs.
3. Appetite: Poor/Medium/excessive
4. Sleep: sound/Disturbed/withcontinuousdreams/insomnia
5. Urination: frequency /day /Night,
Asso. Symptoms: painful/ burning/ excessive/ incontinence/
suppression
6. Defecation: regular/irregular,satisfactory/non
satisfactory,hard/ semi solid/sticky

3.
Asso.Symp.:painful/burning/with blood/with mucus/suppression
7. Flatus: normal/with sound/bad smell/suppression
8. Menstruation:
regular/irregular,painful/painless/heavy/moderate/ scanty
10. Delivery /Abortion/Miscarriage
11. Emotional makeup:
Prakrita/Utsahita/Udrikta/Khinna/Avasadita/ Bhavanatmaka
/Bhawaheena
Samanya Pariksha (General Examination)
Nadi Pariksha: Jihva:
Netra: Tvacha:
Mala: mootra:
B.P.: Pulse:
Temperature: Respiration:
Atura Bala Pariksha(Assessment of Patient strength)
1. Prakriti(Constitution)Vatta/Pitta/Kaphaja/VattPitt/PittKapha/Va
ttKapha/Sama
2. Sara(Excellence Of tissues)–Pravara/Madhyama/Avara
3. Samhanana(Physique)‐Pravara/Madhyama/Avara
4. Pramana: Ht. cm,Wt. Kg..BMI: kg/m2
5. Satmya–Pravara/Madhyama/Avara
6. Satva: Pravara/Madhyama/Avara
7. Aaharsakti:Vishama/Sama/Manda / Tikshna
8. Vyayamasakti/Bala(Strength) –
9. Vaya(Age) –Balyavashtha/Yuvavastha/Vriddhavastha

4.
SYSTEM EXAMINATION
1. GASTROINTESTINAL TRACT
2. RESPIRATORY TRACT
3. MUSCULOSKELETAL SYSTEM
4. NERVOUS SYSTEM

5.
5. URINARY SYSTEM
6. .CARDIOVASCULAR SYSTEM
7. OTHERS

6.
LABORATORY INVESTIGATIONS
BLOOD
HB TLC DLC ESR
SEROLOGY
BIOCHEMISTRY
URINE
ROUTINE:
MICROSCOPE:
STOOL:

7.
X-RAY:
USG:
OTHERS:
 Provisional diagnosis:‐
 Differential Diagnosis:‐
 Final Diagnosis:‐
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