Gujarat Ayurveda University, Jamnagar
Name of the College
DEPARTMENT OF SHALYA TANTRA
Date: ______________
Name of the Patient: _______________________________________________________________
Age: _________________ Gender: ___________ Occupation:_____________________
Residential Address: _______________________________________________________________
_______________________________________________________________
__________________________ Contact No: ___________________
OPD No.:________Ward: _______ Date of Admission: _______ Diagnosis ______________
IPD No. : _______ Bed No.: _____ Date of Discharge: ________Status at discharge_______
Chief Complaints with Duration (Pradhan vedana Avadhi Sahitam):
History of Present Illness (Vedanavrutta):
History of Past Illness (Poorvavyadhivrutta):
Personal History(Vyaktigatvrutta):
Type of Occupation: (Vishesha Vyayam)_____________________
Allergy/Asatmya: ___________________
Food type: Ahaar (Samish/Niramish/Mix )________________________
Sleep(Nidra) : _________________________
Exercise(Vyayam) : ________________________
Defecation(Malapravruti) : __________________________
Addiction (Vyasan):________________________
Urination (Mutrapravruti): __________________________
Family History (Kulavrutta):
Father: _________________ Son: ___________________Husband / Spouse: ______________
Mother: ________________ Daughter: ______________Brother / Sister: _________________
Page 1 of 5
Examination of the Patient:
(A) Vital Data:
Pulse (Naadi): ______________ Temperature(Tapman): _______________
BP(Raktachapa): ______________ Respiration (Swasana): ___________
Level of consciousness ( Sangna):
(Oriented/Disoriented/Stupor/Coma/Death): _______________________
(B) General Examination of Patient(Samanya Pariksha):
Body Built (Samsthana): _________ Lips(Oshtha): _____________________
Nail (Nakha): _______________ Tongue (Jhiva): ______________
Ear (Karna): ________________
Skin (Tvaka): _______________ Eye(Netra): _________________
Nose (Nasa): ____________________
(C) Local Examination(Sthanik Pariksha):
Inspection:
Palpation:
Percussion:
Auscultation:
Regional Lymph Node Examination:
Specific Examinations:
(D) Systemic Examination(Sansthanik parikshan):
G.I.:
CVS:
RS:
GUS:
NS:
Endocrine System:
Others:
Page 2 of 5
(D) Special Investigations (Vishesha Parikshan):
1. Laboratory Investigations(Prayogashaliya parikshana) (Blood, Urine, Biopsy etc.):
2. Radiology Investigation (X-Ray, USG, CT scan, Doppler Study, MRI, ECG, etc.):
Disease Examination (Vyadhi Parikshan):
Etiology(Nidana):
Prodromal Features(Purvarupa):
Clinical Features(Rupa):
Therapeutic Test (Upshayaanupshaya):
Pathological Factors(Samprapti Ghatak):
Vitiated Hummer(Dosha): ______________ VitiateTissue(Dushya): _____________
Site of Disease(Sthana):_________
Type of Disease(Vyadhibheda):
Provisional Diagnosis (Sambhavita vyadhi):
Differential Diagnosis(Sapeksha nidaan):
Final Diagnosis(Vyadhi vinishchaya):
Prognosis: Curable / Surgically Curable / Incurable
Page 3 of 5
Treatment: Palliative/ Surgical/Parasurgical:
Date Symptoms Treatment
Preoperative Note (Poorvakarma):
Operative Note (Pradhanakarma):
Postoperative Note (Pashchatkarma):
Complications(Upadrava):
Post operative regimen(Rakshavidhana):
Pathya:
Apathya:
Page 4 of 5
Result: (Cured /Symptomatic relief /Referred /LAMA/Died)
Sign of Teacher
Name & Sign of Student Department Of ShalyaTantra
Suggestions:
1. Logo of the university should be on the cover page and the Certificate only.
2. Signature of Head of Department on the certificate and Form list.
Page 5 of 5
Page 6 of 5
