1.
GOVERNMENT AYURVEDIC COLLEGE, PATIALA.
DEPARTMENT OF ROG NIDAN EVUM VIKRITI VIGYAN
Name: OPD No: Date:
Age: Gender: M/F
Occupation:
Address:
Marital Status:
Chief Complains with Duration:
History of Present Illness:
Past History:
Family History:
Personal History:
General Examinations: Pulse: Blood Pressure:
Appetite:
Temperature: Sleep:
Ashtavidha Pariksha:

2.
Nadi: Mutra:
Mala: Jibhwa:
Sabda: Sparsha:
Druk: Akruti:
Srotas Parikshana(Involved)
System Examination(Involved)
Investigation Reports(If Any)
Vyadhi Ghatak:
Dosha: Dushya:
Agni: Ama:
Sambhavit Nidana(Provisional Diagnosis)
Student’s Signature Teacher's Signature