Name of College with LOGO

AYURVEDACHARYA (B.A.M.S.)

THIRD PROFESSIONAL B.A.M.S.

<< Subject Name >>

(SUBJECT CODE : AyUG- )

JOURNAL /ACTIVITY BOOK

Name of the student :

Institutional Roll No. :

Examination Reg. No. :

Academic Year :
 (Name of the College)

(Affiliated to –National Commission for Indian System of Medicines, New Delhi &

Name of the University)

Name of the department

Batch- ___________

Certificate
This is to certify that, Mr. / Ms. ________________________________________, Enrolment
Number-________________ has satisfactorily completed the Practicals in (Subject Name
) prescribed by the (Name of University) as a part of the Third Professional B.A.M.S.
Course.

Examination Seat No.: _______________

Sign. of Teacher Sign. of H.O.D.

Date of Examination- _______________

Sign. Of Internal Examiner-______________

Sign. Of External Examiner-________________

 JOURNAL /ACTIVITY BOOK

<< Subject name >>

(SUBJECT CODE : AyUG - )

Journal Cum Activity Book

DEPARTMENT OF
<< Name of Department >>
Name of the College
 INDEX

Sr Topic Date Page

no no
1
2
3
4
Components of Record with instructions
1. Medical Equipment
Identify and write the clinical uses of the given medical equipment in the given format.
➢ Name of the equipment
➢ Clinical uses
List of medical equipments
➢ Ryle's tube
➢ Rubber catheter
➢ Foley's catheter
➢ Nebulizer
➢ HFNC mask
➢ Ambu bag
➢ Urine bag
➢ Defibrillator
➢ Distilled water
➢ Syringe
➢ Insulin syringe
➢ Intravenous Infusion set
➢ Scalp vein set/ Intravenous cannula
2. Life-saving medicines
a. Name of the medicine
b. Indications of the medicine
c. Contraindications of the medicine
d. Clinical use, dose, and the medicine's delivery mode.
3. Medical procedure
Format for Procedure Writing:
Detailed description of Essential Competency-Based Procedures
➢ Name of the procedure:
➢ Indications:
➢ Contraindications:
➢ Preparatory Steps (Poorva Karma):
➢ Main Procedure (Pradhana Karma):
➢ Post-Procedure Care (Pashchat Karma):
➢ Precautions, Possible Complications, and Management:
➢ The student must perform the procedure at least 3 times and be certified by the mentor.
List of procedures /Skill lab activities
➢ Insertion of Nasogastric tube/ Ryle’s tube in a Mannequin
➢ Insertion and removal of an indwelling Urethral Catheter
➢ Nebulization
➢ Oxygen therapy
➢ Cardiopulmonary Resuscitation (CPR)
4. Field visits
A. Visit Details:
a. Date:
b. Location (Name and address):
c. Objectives of the visit:
d. Duration of the visit:
e. Name of facilitators of the Visit:
B. Observations of the visit
a. Brief Summary of the visit:
b. Learnings from the visit:
c. Future applications:
d. Areas for Improvement:
C. Conclusion
Evaluation of the visit (Effectiveness in meeting visit objectives)
D. Pasting the Geotagged photographs of the Visit
➢ DOTs Centre (Please refer to NLHP13.9)
➢ Mental Hospital /De-addiction center/Psycho-social rehabilitation center. (Please
refer to NLHP18.2)
➢ Senior citizens’ home/Geriatric care center. (Please refer to NLHP 25.2)
5. Commemoration of medically important days

• Name of the international day

 • Date of observation
• Organization body (UN/WHO/UNESCO)
• Official theme (if any)
• Significance of the day (Why is it celebrated, Key message and awareness points)
• Activity title and type
• Objective (What the participants learn/achieve)

➢ World malaria day /World dengue day /World hepatitis day /day of Epidemic
preparedness /National vaccination day /World meningitis day /World encephalitis
day (Please refer to NLHP 5.2)
➢ World Liver Day/ World Hepatitis Day (Please refer to NLHP 7.3)
➢ World Cancer Day / Obesity Day/Diabetes Day (Please refer to NLHP 9.2)
➢ World Stroke Day (Please refer to NLHP 11.3)
➢ World Arthritis Day (Please refer to NLHP 11.4)
➢ World Spine Day (Please refer to NLHP 12.2)
➢ World Colorectal Cancer Awareness Day/World IBS Day/World Piles Day (Please
refer to NLHP 16.2)
➢ Mental Health Day (Please refer to NLHP 18.3)
➢ International day of older people (Please refer to NLHP 25.3)
➢ National STD Awareness Week (Please refer to NLHP 22.1)
6. Scientific Journal Reading and presentation
Students should document the following details in the activity book for the chosen
scientific/research article.
a) Name of the research article
b) Name of the author/authors
c) Name of the journal with details of volume, issue
d) Reason for the selection of the particular article
e) Summary of the article in 250-300 words.
f) Merits and limitation of the articles
➢ Tvak Vikara
 ➢ Irritable Bowel Syndrome/ (Grahani)
➢ Rasayana
7. Long case (20 Cases) + Rasayana-Vajikarana Cases (5 cases)
➢ 20 Long cases (at least one case from each srotas + Antahsravi granthi Vikara + 2
cases of Manasa roga). Please follow the given template.
➢ 3 Rasayana cases + 2 Vajikarana cases (Total 5 cases). Please follow the given
template.
8. Short case (20 Cases)
20 Short cases (at least one case from each srotas + Kshudra roga) + Please follow the
given template.
9. NLHT activity
➢ Date of the activity
➢ Name of the Activity
➢ Role of the student
➢ Role of the faculty
➢ Assessment – Cognitive Domain
➢ Method undertaken
➢ Know how/Know
➢ Remarks
 Uses of Medical Equipment
Write the clinical uses of the given medical equipment.
➢ Name of the equipment:

➢ Clinical uses:

➢ Photograph of the equipment:

List of medical equipments:

• Ryle's tube
• Rubber catheter
• Foley's catheter
• Nebulizer
• HFNC mask
• Ambu bag
• Urine bag
• Defibrillator
• Distilled water
• Syringe
• Insulin syringe
• Intravenous Infusion set
• Scalp vein set/ Intravenous cannula
 Uses of the Lifesaving medicine
➢ Name of the medicine:

➢ Indications of the medicine:

➢ Contraindications of the medicine:

➢ Clinical use, dose, and the medicine's delivery mode.:

 Medical procedure
➢ Description of Essential Competency-Based Procedures. (The student must perform
the procedure at least 3 times and be certified by the mentor.)

➢ Name of the procedure:

➢ Indications:

➢ Contraindications:

➢ Preparatory Steps (Poorva Karma):

➢ Main Procedure (Pradhana Karma):

➢ Post-Procedure Care (Pashchat Karma):

➢ Precautions, Possible Complications, and Management:

List of procedures /Skill lab activities

• Insertion of Nasogastric tube/ Ryle’s tube in a Mannequin
• Insertion and removal of an indwelling Urethral Catheter
• Nebulization
• Oxygen therapy
• Cardiopulmonary Resuscitation (CPR)
 Field visit
➢ Date:

➢ Location (Name and address):

➢ Objectives of the visit:

➢ Duration of the visit:

➢ Name of facilitators of the Visit:

➢ Observations of the visit:

➢ Brief Summary of the visit:

➢ Learnings from the visit:

➢ Future applications:

➢ Areas for Improvement:

➢ Evaluation of the visit (Effectiveness in meeting visit objectives):

➢ Pasting the Geotagged photographs of the Visit:

List of field visits:

• DOTs Centre (Please refer to NLHP13.9)
• Mental Hospital /De-addiction center/Psycho-social rehabilitation center. (Please
refer to NLHP18.2)
• Senior citizens’ home/Geriatric care center. (Please refer to NLHP 25.2)
 Commemoration of medically important days
➢ Name of the international day:

➢ Date of observation:

➢ Organization body (UN/WHO/UNESCO):

➢ Official theme (if any):

➢ Significance of the day (Why is it celebrated, Key message, and awareness points):

➢ Activity title and type:

➢ Objective (What the participants learn/achieve):

List of medically important days:

• World malaria day /World dengue day /World hepatitis day /day of Epidemic
preparedness /National vaccination day /World meningitis day /World
encephalitis day (Please refer to NLHP 5.2)
• World Liver Day/ World Hepatitis Day (Please refer to NLHP 7.3)
• World Cancer Day / Obesity Day/Diabetes Day (Please refer to NLHP 9.2)
• World Stroke Day (Please refer to NLHP 11.3)
• World Arthritis Day (Please refer to NLHP 11.4)
• World Spine Day (Please refer to NLHP 12.2)
• World Colorectal Cancer Awareness Day/World IBS Day/World Piles Day
(Please refer to NLHP 16.2)
• Mental Health Day (Please refer to NLHP 18.3)
• International day of older people (Please refer to NLHP 25.3)
• National STD Awareness Week (Please refer to NLHP 22.1)
 Scientific Journal Reading and Presentation
Students should document the following details for the chosen scientific/research
article in the activity book.
➢ Name of the research article:

➢ Name of the author/authors:

➢ Name of the journal with details regarding volume and issue:

➢ Reason for the selection of the article:

➢ Summary of the article in 250-300 words:

➢ Merits and limitations of the articles:

List of topics for scientific journal reading and presentations:

• Tvak Vikara
• Irritable Bowel Syndrome/ (Grahani)
• Rasayana
 CONTENTS
Serial No. Vistrita Rugna patraka (Long Case paper) Page No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.

Serial No. Rasayana-Vajikarana Rugna Patraka (Case papers) Page No.

1.
2.
3.
4.
5.
Serial No. Samkshipta Rugna patraka (Short Case paper) Page No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
 Kayachikitsa Vistrita Rugna Patraka (Long Case Paper)
Kramanka (Case No): Bahirkramanka (OPD No): Antarkramanka (IPD No):
Shayya Kramanka (Bed No):
Rugna Nama (Name of the Patient): Vaya (Age): Linga (Gender): M/F/T

Religion: H/M/S/C/J/O
Vaivahika sthiti Unmarried/Married/Divorced/Widowhood
(Marital Status):
Poorva (past): Sadhya (present):
Vyavasaya
(Occupation): Avadhi (working hours): Vritti swabhava (Nature of work):

Shikshana (Education): Uneducated/Lower Primary/SSC/PUC/UG/PG

Samajika arthika sthiti Lower/Middle/Upper
(Socio-economic Status):
Sthana (Address): Contact No.

Pravesha dinanka (Date of admission): Nirgamana dinanka (Date of discharge):

Parinama (Result):

Pradhana vedana (Chief Complaint): Kala Prakarsha (Duration):

Anubandhi vedana (Associated Complaint):

Adyatana vyadhi vrittanta (H/o Present illness):

Saha-vyadhi vrittanta (Comorbidity):

Poorva vyadhi vrittanta (H/o Past illness):

Kautumbika vrittanta (Family history):

Alive Dead Disease Healthy Age

Father
Mother
Spouse
Brother
Sister
Son
Daughter

H/o Tulya gotra vivaha (Consanguinity of marriage): Yes……………. /No………………….

H/o Kulaja vikara vrittanta (Hereditary diseases): Yes……………. /No……………………

Vaiyaktika vrittanta (Personal history):

Ahara prakara (Dietary habits)-Veg/Nonveg/Mixed

Jala pana (water intake)-Hina/Mithya/Ati

Kshudha (Appetite)-Good/Impaired

Ahara sevana-Alpa/Ati/Adhyashana

Mala pravritti (Bowel movement)-

Koshtha: Mridu/Madhyama/Krura

Mutra pravritti (Micturition)-

Nidra (Sleep)-Sound/Disturbed, H/o Diva swapna / Ratri jagarana

Vyasana (Habits / Addiction)-Tea/Coffee/Smoking/Tobacco chewing/Alcohol/Drugs/None

Smoking-Regular/Occasional/Never Smoked/Ex-smoker

Quantity…………/day Duration of smoking……………………

Alcohol intake - No/Social drinker/Habitual

Quantity…………/day Duration of alcohol intake ……………………

Anurjata (Drug sensitivity)-

Chintadhikya (Mental stress) -

Rajopravritti vrittanta (Menstrual history)-

Rogi Pariksha Vidhi:

a) Samanya Pariksha:

Sharira akriti (Body Built): Sanjna (Consciousness): Gati (Gait):

Sharira dairghya (Height): cm Sharira bhara (Weight): Kg Panduta (Pallor):

Netra pitavarnata (Icterus): Nila-shyava varnata (Cyanosis): Clubbing:

Granthi (Lymphadenopathy): Shopha (Oedema): Jihva liptata (Tongue coating):

Nakha (Nails): Anya (Other findings):

Vitals:

Temperature: ºF Heart rate: /min Pulse rate: /min

Blood pressure: mmHg Respiratory rate: /min

b) Samsthanika pariksha/Vishishta pariksha (Systemic Examination):

c) Srotas pariksha:

Srotas Moolasthana Darshanagamya Sparshanagamya Prashnagamya

Vishaya Vishaya Vishaya

d) Ashta sthana pariksha:

Nadi: Shabda:

Mootra: Sparsha:

Mala: Drik:

Jihva: Akriti:

e) Dashavidha Pariksha:

1. Prakriti Shareerika Prakriti V P K VP VK PK S

Manasika Prakriti Sattva Rajas Tamas
Shhareerika V P K
Dosha
Manasika Satvika Rajasika Tamasika
Dooshya Rasa Rakta Mamasa Medas Asthi Majja Shukra
2. Vikriti
Pureesha Frequency Consistency
Mala Mootra Frequency Consistency
Sweda Normal Abnormal
3. Sara T R M M A M S S
4.
Heena Madhyama Uttama
Samhanana
5. Pramana Heena Madhyama Uttama
6. Satmya Heena Madhyama Uttama
7. Ahara Abyawarana Shakti Avara Madhyama Pravara
Shakti Jarana Shakti Avara Madhyama Pravara
8. Vyayama
Heena Madhyama Uttama
Shakti
9. Vaya Bala Madhyama Vriddha
10. Sattva Heena Madhyama Uttama

f) Prayogashaliya Parikshana (Investigations):

Roga Pariksha:

A) Nidanapanchaka

Nidana:

Poorvarupa:

Rupa:

Upashaya/Anupashaya:

Samprapti:

B) Samprapti ghataka

Dosha:

Dushya: Dhatu/Upadhatu/Mala

Srotas:

Srotodushti prakara:

Udbhava sthana:

Sanchara sthana:

Vyakta sthana:
Adhisthana:

Rogamarga:

Vyadhi avastha vishesha (Stage of the disease):

Sama/Nirama Kevala Dosha/ Avritta Dosha

Nava/Purana Samsrushta/Sannipata Dosha
Uttana/Gambhira

Vyavachedaka Nidana (Differential Diagnosis):

Vyadhi nama (Diagnosis):

Upadrava:

Arishta Lakshana:

Sadhya-Asadhyata:

CHIKITSA
Chikitsa Sootra:

Chikitsa:

1. Yuktivyapashraya Chikitsa:

A) Shodhana

Vamana/Virechana/ Basti/ Nasya/Raktamokshana

B) Shamana

Bahya Chikitsa:

Chikitsa Aushadha Kala

Abhyantara Chikitsa:

Kalpa Matra Kala Anupana

2. Daivavyapashraya Chikitsa:

3. Satvavajaya Chikitsa:

Pathya/Apathya:

Pathya: Ahara:

Vihara:

Apathya:Ahara:

Vihara:

Dainika Patraka:

Dinanka Vishesha avastha/ Upayukta aushadha Parinama

Navina lakshana yoga
utpatti
Dainandika akalana (Daily Assessment):

Karya Dainandika Nireekshana (Daily observation) Prapti/Alpa-prapti/Aprapti

1 2 3 4 5 6 7 8 9 10
Ruk Upashamanam
(Reduction of Pain)
Annabhilasha (Desire for the
intake of food)
Bhuktasya paripaka (Proper
and easy digestion of the
ingested food)
Srishta vit (Proper evacuation
of faeces)
Srishta mootra(Proper
evacuation of urine)
Srishta vata (Proper
evacuation of flatus)
Shareera laghava (Lightness in
the body)
Prasannendriya (Optimum
functioning of sense organs)
Sukha swapna (Proper timely
sleep)
Vaikarikanam cha swapnam
adarshanam (Devoid of
unpleasant dreams)
Sukha prabodhanam (Proper
timely awakening)
Bala labha (Gain of strength)
Varna labha (Improved
complexion)
Swara yoga (Pleasant voice)
Ayusho labha (Improved
quality of life)
Soumanasyam (Pleasant mind)
Samagni (Normal digestive
fire)

Karyaphala:

Manobuddhindriyasharira tushti
Vikara upashamana
Muchyamana
Pragunibhava
Anya

Vidyarthi Hastakshara Adhyapaka Hastakshara

 Kayachikitsa Manasa-Roga Rugna Patraka
(Kayachikitsa Manasa-Roga Case Paper)

VITAL DATA
Kramanka (Case No): Bahirkramanka (OPD No): Antarkramanka (IPD No):
Shayya Kramanka (Bed No):
Rugna Nama (Name of the Patient): Vaya (Age): Linga (Gender): M/F/T

Religion: H/M/S/C/J/O
Vaivahika sthiti Unmarried/Married/Divorced/Widowhood
(Marital Status):
Poorva (past): Sadhya (present):
Vyavasaya
(Occupation): Avadhi (working hours): Vritti swabhava (Nature of work):

Education: Uneducated/Lower Primary/SSC/PUC/UG/PG

Samajika arthika sthiti Lower/Middle/Upper
(Socio-economic Status):
Sthana (Address): Contact No.

Pravesha dinanka (Date of admission): Nirgamana dinanka (Date of discharge):

Parinama (Result):

Informant: Self/parents/Relatives/Spouse/friends/Neighbors/other
Name of the informant:

Source of Pradhana vedana Kala

information (Presenting complaints) prakarsha
(Duration)

Patient

Informant

Anubandhi vedana (Associate complaints) with the duration:

Adyatana vyadhi vrittanta (History of present illness):

Saha vyadhi vrittanta (Comorbidity):

Poorva-vyadhi vrittanta (history of previous illness):

Psychiatric history:
K/C/O Any psychiatric disease: Yes / No
If yes,

Suicidal behavior: Suicidal ideation - Yes / No Suicidal attempts - Yes /No

No. of attempts:
Reasons:
Other details:

Organic disease history: Yes / No

If yes,

Legal history: Present/Absent

Drink and drive: Present/Absent
Any history of road accidents due to alcohol abuse: Present/absent
Any history of crimes: Sexual offences/Violence/Murders/Fraud: Present/absent
Any history of legal punishment: Present/absent

Chikitsa vrittanta (Treatment history) :

Treatment taken: Yes/No
If yes;
Previous hospitalization: Yes/No

Kautumbika vrittanta (Family history):

1. Family atmosphere: Harmonious/Complicated
2. Marital disharmony of parents: Yes/No
3. Psychiatric abnormality in the family: Yes/No
4. Organic diseases in the family: Yes/No
5. Family Problems: Yes/No
6. Drug addiction or alcoholic in family: Yes/No
7. Family breakup: Yes/No
8. Death of any Immediate family member(s): Yes/No

9. History of suicide(s) in the family: Yes/No

10. Childhood abuse: Yes/No
11. Tulya gotra vivaha (Consanguinity of marriage): Yes/No
12. Kulaja vikara vrittanta (Hereditary disease): Yes/No
If yes:

13. Other:
1) None 2) Displacement in childhood
3) Children related problems 4) Isolated Family

Family member Alive Dead Disease Healthy Age

Father
Mother
Spouse
Brother
Sister
Son
Daughter

Janma evum balaka vrittanta (Birth and childhood history):

1. Place of birth: Pregnancy: Planned /Unplanned
2. Length of gestation: Gender Acceptance by Family: Yes/No
3. Nature of delivery: Normal/CS/Forceps/Precipitate/Premature/ Post-mature
 4. Mother’s health during pregnancy: Normal/Abnormal
5. Milestones & Developments: Normal/Delayed
6. Childhood illness: Epilepsy/Meningitis/Encephalitis/Other
7. Playing alone: Yes/No
8. Any particular fear: Yes/No
9. Physical symptoms at the time of stress or unhappiness: Yes/No
10. Any physical disorder: Yes/No
11. Any emotional disorders: Enuresis/Tics/Nail biting/temper tantrum/Head banging/others
12. Any specific: Domestic violence/Harassment/separation from parents/ sibling rivalry: Yes/No

Vartamana samajika sthiti (Present social situation):

1. Social relations: Satisfactory/Unsatisfactory

Vaivahika vrittanta (Marital history):

1. Relationship with Spouse: Satisfactory/Unsatisfactory
2. Discussion with spouse before taking decisions: Present/Absent
3. Sharing responsibilities/household works: Present/Absent
4. Early/Timely/ Late marriage; Arranged marriage / Not with the consent of the family
5. Sexual Satisfaction Present/Absent
6. If divorce, reason:
7. Any Extramarital/Premarital Experiences: Present/Absent
8. Do you have:
Reduced Libido ꙱ Excessive Sexual Urge ꙱ Complete Abstinence ꙱
Erectile Dysfunction ꙱ Delayed Ejaculation ꙱ Pathological Jealousy ꙱

Menstrual and obstetric history:

1. Menarche:
2. Menopause:
3. Menstrual cycle: Days: Regular/Irregular
4. Whether the complaints aggravating during the menstrual period: Yes /No
5. Pre-menstrual syndromes: Yes/No
6. Number of deliveries:
7. Nature of delivery: Normal/C.S./Forceps/Precipitate/Premature/Post-mature
8. Abortion:
9. Other complications:

Personal history:
1. Ahara prakara (Dietary habits): Veg/Mix
Samashana /Adhyashana/Vishamashana /Pramitashana/Regular/Irregular
2. Supplementary Diets - Tea/Coffee/Cold Drinks /Other Quantity:
3. Kshudha (Appetite)-Good/Impaired
4. Ahara sevana-Alpa/Ati/Adhyashana
5. Jala pana (water intake)-Heena/Mithya/Ati
6. Exercise - Regular/Irregular/No/Less/Proper/Excess
 7. Rest_____________hrs/day
8. Snana - Daily/Irregular
9. Nidra- Alpa/Prabhuta/Khandita _________hrs/day; __________hrs/night
10. Mala pravritti (Bowel movement)
11. Koshtha: Mridu/Madhyama/Krura
12. Mootra pravritti (Micturition)
13. Anurjata (Drug sensitivity)
14. Hobbies:
15. Vyasana (Addictions): Present/Absent
If present, Duration: Substance(s): Quantity:

Rogi pareeksha vidhi:

Samanya pareeksha:
Shareera akriti (Body Built): Samjna (Consciousness):
Gati (Gait): Shareera dairghya (Height):
Shareera bhara (Weight): Panduta (Pallor):
Netra peetavarnata (Icterus): Neela-shyava varnata (Cyanosis):
Clubbing: Granthi (Lymphadenopathy):
Shopha (Oedema): Jihva liptata (Tongue coating):
Nakha (Nails):
Anya (Other findings):

Vital signs examination:

Pulse rate R: L:
Respiratory rate
Blood pressure
Temperature
Heart rate

Systemic examination:
1. Respiratory system:

2. Gastrointestinal System:

3. Cardiovascular System:
 4. Nervous System:

Ashtasthana pareeksha

Nadi: Shabda:

Mootra: Sparsha:

Mala: Drik:

Jihva: Akriti:

Dashavidha pareeksha

1. Prakriti Shareerika Prakriti V P K VP VK PK S

Manasika Prakriti Sattva Rajas Tamas
Shhareerika V P K
Dosha
Manasika Satvika Rajasika Tamasika
Dooshya Rasa Rakta Mamasa Medas Asthi Majja Shukra
2. Vikriti
Pureesha Frequency Consistency
Mala Mootra Frequency Consistency
Sweda Normal Abnormal
3. Sara T R M M A M S S
4.
Heena Madhyama Uttama
Samhanana
5. Pramana Heena Madhyama Uttama
6. Satmya Heena Madhyama Uttama
7. Ahara Abyawarana Shakti Avara Madhyama Pravara
Shakti Jarana Shakti Avara Madhyama Pravara
8. Vyayama
Heena Madhyama Uttama
Shakti
9. Vaya Bala Madhyama Vriddha
10. Sattva Heena Madhyama Uttama
Manovaha sroto pareeksha (Mental status examination):
Manovibhrama
Indriyabhigraha (Perception and motor control)
Hallucinations Absent Present
Illusions Absent Present
Manonigraha (Mental Control) Absent Present
Chintya (process of thinking) Absent Present
Negatively biased thoughts
Vicharya (Thoughts)
Flight of ideas Absent Present
Blocking of thoughts Absent Present
Thought broadcasting Absent Present
Thought control by others Absent Present
Obsession and fixed ideas Absent Present
Sudden strange ideas Absent Present
Oohya
Pessimistic Speculation Absent Present
Dhyeya (Contemplation) Absent Present
Assessment of events hurting,
harming, and pessimistic
Sankalpa (Conviction) Absent Present
pessimistic emotional judgment
Buddhi vibhrama (Intellectual Capacity)
Mental deficiency Absent Present
General information Good Bad
Immature behavior Absent Present
Imitation Absent Present
Insight Absent Present
Judgment Absent Present
Delusions Absent Present
Samjnajnana vibhrama (Consciousness/Orientation/Responsiveness)
Orientation to time Intact Impaired
Orientation to the place Intact Impaired
Orientation to a person Intact Impaired
Attention Absent Present
Concentration Absent Present
Smriti vibhrama (Memory)
Remote Absent Present
Recent Absent Present
Immediate Absent Present
Bhakti vibhrama (Desire)
Food Normal Impaired
Dress Normal Impaired
Sex Normal Impaired
Entertainment Normal Impaired
Sheela vibhrama (Temperament)
Change in Emotions like: Absent Present
Elation:
Anger:

Anxiety:

Depression:
Fear:

Anti-social behavior:

Leisure time activities:

Solitude: Absent Present
Cheshta vibhrama
General psycho motor Absent Present
activity: (Tick the relevant
finding)
Speech:

Facial expression:
Posture:

Tics:

Achara vibhrama
Personal Standard:

Habit of cleanliness:

Neglect of daily routine and

work:

Obsessions in work:

Social Standard:

Nudity:

Religious beliefs:
Any other:

Prayogashaleeya pareekshana (Laboratory investigations):

Vikriti pareeksha:
Nidana:

Poorvaroopa:

Roopa:

Upashaya/anupashaya:

Samprapti:
Samprapti ghataka:
• Dosha (Kayika/Manasika)

• Dooshya

• Agni

• Ama

• Srotas

• Dushti prakara

• Udhbavasthana

• Sancharasthana

• Adhishthana

• Vyaktasthana

• Rogamarga

Vyadhi avastha:

Vyavachchedaka nidana (Differential diagnosis)

Vyadhi nama (Diagnosis):

Upadrava:

Arishta lakshana:

Sadhya-Asadhyata:

CHIKITSA
Chikitsa Sootra:

Yuktivyapashraya (Methods and duration):

Shodhana:
Vamana/ Virechana/ Basti/ Nasya/ Raktamokshana

Shamana procedures:

Rasayana procedures:

Bahya chikitsa:
Chikitsa Aushadha Kala
Abhyantara chikitsa:
Kalpa Matra Anupana Kala

Daivavyapashraya (Methods and duration):

Mantra (Hymns/ Prayer)

Aushadha (Medicine)

Mani (Wearing of precious gems)

Mangala (Auspicious ceremony)

Bali (Sacrifice/ Offering to God)

Upahara (Gift)

Homa (Oblations)

Niyamana (Observance of scriptural rules)

Prayashchita (Atonement)

Upavasa (Fasting)

Svastyayana

(Chanting of auspicious hymns)

Pranipata (Observance of the god)

Gamana (Going on pilgrimage)

Satvavajaya (Methods and duration)

Aashvasana (Assurance)

Pratidvandva chikitsa

(Replacement of emotions)

Chintya (Regulation of thought

process)

Vicharya (Retraining of ideas)

Oohya (Channeling of

presumptions)

Dhyeya (Correction of objectives

and ideas)

Sankalpa (Proper guidance and

advice for taking right decisions)

Dhriti (Proper control/patience)

Manokshobha chikitsa (Fear

therapy or Psycho-shock therapy)

Pathya/Apathya:
Pathya ahara:

Pathya vihara:

Apathya ahara:

Apathya vihara:
Dainika Patraka

Dinanka Vishesha avastha/ Navina Upayukta aushadha yoga Parinama

Lakshana utpatti
Dainandika akalana (Daily assessment):
Dainandika Nireekshana (Daily observation)
Prapti/Alpa-prapti/Aprapti
Karya
1 2 3 4 5 6 7 8 9 10

Ruk Upashamanam (Reduction of Pain)

Annabhilasha (Desire for the intake of food)

Bhuktasya paripaka (Proper and easy digestion

of the ingested food)

Srishta vit (Proper evacuation of faeces)

Srishta mootra (Proper evacuation of urine)

Srishta vata (Proper evacuation of flatus)

Sharira laghava (Lightness in the body)

Prasannendriya (Optimum functioning of sense

organs)

Sukha swapna (Proper timely sleep)

Vaikarikanam cha swapnam adarshanam

(Devoid of unpleasant dreams)

Sukha prabodhanam (Proper timely awakening)

Bala labha (Gain of strength)

Varna labha (Improved complexion)

Swara yoga (Pleasant voice)

Ayusho labha (Improved quality of life)

Soumanasyam (Pleasant mind)

Samagni (Normal digestive fire)

Karyaphala:
Manobuddhindriyasharira tushti
Vikara upashamana
Muchyamana
Pragunibhava
Anya

VIDYARTHI HASTAKSHARA ADHYAPAKA HASTAKSHARA

 Rasayana-Vajikarana Rugna Patraka (Rasayana-Vajikarana Case Paper)
Kramanka (Case No): Bahirkramanka (OPD No): Antarkramanka (IPD No):
Shayya Kramanka (Bed No):
Rugna Nama (Name of the Patient): Vaya (Age): Linga (Gender): M/F/T

Religion: H/M/S/C/J/O
Vaivahika sthiti Unmarried/Married/Divorced/Widowhood
(Marital Status):
Poorva (past): Sadhya (present):
Vyavasaya
(Occupation): Avadhi (working hours): Vritti swabhava (Nature of work):

Shikshana (Education): Uneducated/Lower Primary/SSC/PUC/UG/PG

Samajika arthika sthiti Lower/Middle/Upper
(Socio-economic Status):
Sthana (Address): Contact No.

Pravesha dinanka (Date of admission): Nirgamana dinanka (Date of discharge):

Parinama (Result):

Pradhana vedana (Chief Complaint): Kala Prakarsha (Duration):

Anubandhi vedana (Associated Complaint):

Adyatana-vyadhi vrittanta (H/o Present illness):

Saha-vyadhi vrittanta(Comorbidity):

Poorva-vyadhi vrittanta (H/o Past illness):

Kautumbika vrittanta (Family history):

 Alive Dead Disease Healthy Age
Father
Mother
Spouse
Brother
Sister
Son
Daughter

H/o Tulya gotra vivaha (Consanguinity of marriage): Yes……………. /No………………….

H/o Kulaja vikara vrittanta (Hereditary diseases): Yes……………. /No……………………

Vaiyaktika vrittanta (Personal history):

Ahara prakara (Dietary habits)-Veg/Nonveg/Mixed

Jala pana (water intake)-Hina/Mithya/Ati

Kshudha (Appetite)-Good/Impaired

Ahara sevana-Alpa/Ati/Adhyashana

Mala pravritti (Bowel movement)-

Koshtha: Mridu/Madhyama/Krura

Mutra pravritti (Micturition)-

Nidra (Sleep)-Sound/Disturbed, H/o Diva swapna / Ratri jagarana

Vyasana (Habits / Addiction)-Tea/Coffee/Atilavana/Atikshara/Atikatu/Smoking/Tobacco

chewing/Alcohol/Drugs/None

Smoking-Regular/Occasional/Never Smoked/Ex-smoker

Quantity…………/day Duration of smoking……………………

Alcohol intake - No/Social drinker/Habitual

Quantity…………/day Duration of alcohol intake ……………………

Anurjata (Drug sensitivity)-

Chintadhikya (Mental stress) -

Rajopravritti vrittanta (Menstrual history)-

Rogi pareeksha:

a) Samanya Pareeksha:

Sharira akriti (Body Built): Sanjna (Consciousness): Gati (Gait):

Sharira dairghya (Height): cm Sharira bhara (Weight): Kg Panduta (Pallor):

Netra pitavarnata (Icterus): Nila-shyava varnata (Cyanosis): Clubbing:

Granthi (Lymphadenopathy): Shopha (Oedema): Jihva liptata (Tongue coating):

Nakha (Nails): Anya (Other findings):

Vitals:

Temperature: ºF Heart rate: /min Pulse rate: /min

Blood pressure: mmHg Respiratory rate: /min

b) Samsthanika pareeksha/Vishishta pareeksha (Systemic Examination):

c) Srotas pareeksha:

Srotas Moolasthana Darshanagamya Sparshanagamya Prashnagamya

vishaya vishaya vishaya

d) Ashta-sthana pareeksha:
Nadi: Shabda:

Mootra: Sparsha:

Mala: Drik:

Jihva: Akriti:

e) Dashavidha pareeksha:

1. Prakriti Shareerika Prakriti V P K VP VK PK S

Manasika Prakriti Sattva Rajas Tamas
Shhareerika V P K
Dosha
Manasika Satvika Rajasika Tamasika
Dooshya Rasa Rakta Mamasa Medas Asthi Majja Shukra
2. Vikriti
Pureesha Frequency Consistency
Mala Mootra Frequency Consistency
Sweda Normal Abnormal
3. Sara T R M M A M S S
4.
Heena Madhyama Uttama
Samhanana
5. Pramana Heena Madhyama Uttama
6. Satmya Heena Madhyama Uttama
7. Ahara Abyawarana Shakti Avara Madhyama Pravara
Shakti Jarana Shakti Avara Madhyama Pravara
8. Vyayama
Heena Madhyama Uttama
Shakti
9. Vaya Bala Madhyama Vriddha
10. Sattva Heena Madhyama Uttama
f) Prayogashaleeya pareekshana (Investigations):
Roga Pareeksha:

Nidana:

Poorvaroopa:

Roopa:

Upashaya/Anupashaya:

Samprapti:

Dosha:

Dooshya: Dhatu/Upadhatu/Mala

Ojas: Anuloma/ Pratiloma kshaya

Srotas:

Srotodushti prakara:

Udbhava sthana:

Sanchara sthana:

Vyakta sthana:

Adhisthana:

Rogamarga:

Vyadhi avastha vishesha (Stage of the disease):

Sama/Nirama Kevala dosha/ Avritta dosha

Nava/Purana Samsrushta/Sannipata dosha
Uttana/Gambhira

Vyavachedaka nidana (Differential diagnosis):

Vyadhi nama (Diagnosis):

Upadrava:

Arishta lakshana:

Sadhya-Asadhyata:

CHIKITSA
Shodhana

Vamana/Virechana/ Basti/ Nasya/Raktamokshana

Bahya Chikitsa:

Chikitsa Aushadha Kala

Abhyantara Chikitsa:

Kalpa Matra Kala Anupana

Rasayana / Vajikarana

Kalpa Matra Kala Anupana Avadhi

2. Daivavyapashraya Chikitsa:
3. Satvavajaya Chikitsa:

Pathya/Apathya:

Pathya: Ahara:

Vihara:

Apathya:Ahara:

Vihara:

Dainandika akalana (Daily Assessment):

Karya Dainandika Nireekshana (Daily observation) Prapti/Alpa-prapti/Aprapti

1 2 3 4 5 6 7 8 9 10
Ruk Upashamanam
(Reduction of Pain)
Annabhilasha (Desire for the
intake of food)
Bhuktasya paripaka (Proper
and easy digestion of the
ingested food)
Srishta vit (Proper evacuation
of faeces)
Srishta mootra(Proper
evacuation of urine)
Srishta vata (Proper
evacuation of flatus)
Shareera laghava (Lightness in
the body)
Prasannendriya (Optimum
functioning of sense organs)
Sukha swapna (Proper timely
sleep)
Vaikarikanam cha swapnam
adarshanam (Devoid of
unpleasant dreams)
Sukha prabodhanam (Proper
timely awakening)
Bala labha (Gain of strength)
Varna labha (Improved
complexion)
Swara yoga (Pleasant voice)
Ayusho labha (Improved
quality of life)
Soumanasyam (Pleasant mind)
Samagni (Normal digestive
fire)

Karyaphala:

Manobuddhindriyasharira tushti
Vikara upashamana
Muchyamana
Pragunibhava
Anya

Vidyarthi Hastakshara Adhyapaka Hastakshara

 Kayachikitsa Samkshipta Rugna Patraka (Short Case Paper)
Kramanka (Case No): Bahirkramanka (OPD No): Antarkramanka (IPD No):
Shayya Kramanka (Bed No):
Rugna Nama (Name of the Patient): Vaya (Age): Linga (Gender): M/F/T

Religion: H/M/S/C/J/O
Vaivahika sthiti Unmarried/Married/Divorced/Widowhood
(Marital Status):
Poorva (past): Sadhya (present):
Vyavasaya
(Occupation): Avadhi (working hours): Vritti swabhava (Nature of work):

Shikshana (Education): Uneducated/Lower Primary/SSC/PUC/UG/PG

Samajika arthika sthiti Lower/Middle/Upper
(Socio-economic Status):
Sthana (Address): Contact No.

Parinama (Result):

Pradhana Vedana (Chief complaint): Kala Prakarsha (Duration):

Anubandhi Vedana (Associated complaint):

VaiyaktikaVrittanta (Personal history):

Kshudha (Appetite): Agni: Sattva:

Nidra (Sleep): Koshtha (Bowel): Vyasana (Habits/Addiction):

Rogi Pariksha:

A) Samanya Pareeksha (General examination):

Sharira Dairghya (Height): cm Sharira Bhaara (Weight): Kg

Nadi (Pulse): /min Raktachapa (Blood pressure): mmHg

Shwasana Gati (Resp.rate): /min Hridgati (Heart rate): /min

Gati (Gait): Anya (Any other):

B) Ashta Sthana Pareeksha:

Nadi: Shabda:

Mootra: Sparsha:

Mala: Drik:

Jihva: Akriti:

C) Vikrita srotas pareeksha (Brief Examination of the involved system):

Roga Pareeksha:

Nidana:

Poorvaroopa:

Roopa:

Upashaya/Anupashaya:

Samprapti:

Dosha:

Dooshya: Dhatu/Upadhatu/Mala

Srotas:

Vyadhi avastha vishesha (Stage of the disease):

Sama/Nirama Kevala Dosha/ Avritta Dosha

Nava/Purana Samsrushta/Sannipata Dosha
Uttana/Gambheera
Vyadhi Nama (Diagnosis):

Chikitsa:

Abhyantara Bahya
Aushadha Matra Anupana Sevana Upakrama Kala Avadhi
yoga kala

Pathya ahara/Vihara

Pathya ahara Pathya vihara – Shareerika /Manasika

Apathya ahara/Vihara

Apathya ahara Apathya vihara-Shareerika/Manasika

Vidyarthi Hastakshara Adhyapaka Hastakshara