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Mamc KC Sheet

The document is a detailed history sheet used by the Motherhood Ayurveda Medical College's Department of Kayachikitsa for patient admission. It includes sections for personal information, medical history, examination findings, and diagnostic assessments. The form is structured to gather comprehensive data on the patient's health status and treatment needs.

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Irish Sense
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118 views12 pages

Mamc KC Sheet

The document is a detailed history sheet used by the Motherhood Ayurveda Medical College's Department of Kayachikitsa for patient admission. It includes sections for personal information, medical history, examination findings, and diagnostic assessments. The form is structured to gather comprehensive data on the patient's health status and treatment needs.

Uploaded by

Irish Sense
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MOTHERHOOD AYURVEDA MEDICAL COLLEGE, ROORKEE,(U.

K)
DEPARTMENT OF KAYACHIKITSA

HISTORY SHEET

Name -: Date of Admission-

Age -: Date of Discharge-

Sex - :

Address - :

Occupation- :

Religion- :

Marital Status- :

Chief Complaints- Duration:-


History of Present illness:-

History of past illness:-

SurgicalHistory:-

TreatmentHistory:-

PersonalHistory:-
Appetite:
Sleep:
Food Habbits:
Addiction: Tobacco / Tea / Coffee / Smoking / Drinking
Bowel Habits: Regular/ Irregular
Micturition: Increased / Decreased frequency / Normal

Family history :-

Occupational History :-

Menstrual History:-
Age of Onset-: Age of menopause-

Quantity-: Duration

Cycle–regular / irregular

Obstretric History:-
Gravida :- Para:- Abortions:-

Mode of deliveries: -
No. of Live children:-

EXAMINATION
1. GENERAL EXAMINATION:-
BUILT:- OEDEMA:-

NUTRITION:- SKIN:-

DECUBITUS:- VERTEBRAL COLUMN:-

CLUBBING:- JOINTS:-

CYANOSIS:- TEMPERATURE:-

JAUNDICE:- BLOOD PRESSURE:-

PALLOR:- PULSE:-

LYMPHADENOPATHY:-
(B) DASVIDHA ATUR BALA PARIKSHA:-

1. Prakriti: Manasika- Satvika / Rajasika / Tamasika


Sharirika- V /P /K / VP / KV / PK / Tridoshaja
2. Vikriti: Prakriti sama samvaya / Vikriti bishama samvaya
3. Sara : Tvak / Rakta / Mamsa / Meda / Asthi / Majja / Shukra /
Stavas / Snigdha / Ruksha
4. Samhanana: Susamhata / Madhya / Heena
5. Pramana: Sama / Madhyama / Heena
6. Satmya: Ekarasa / Sarvarasa / Madhyarasa / Ushna / Sheeta
7. Satva: Pravara / Madhyama / Avara
8. Aahara Shakti:
(a) Abhyavaharana Shakti (matra)
Vyadhi Purva- Pravara / Madhyama / Avara
Vyadhi Paschata- Pravara / Madhyama / Avara
(b) Jarana Shakti
Vyadhi Purva- Pravara / Madhyama / Avara
Vyadhi Paschata- Pravara / Madhyama / Avara
9. Vyayama Shakti : Pravara / Madhyama / Avara
10. Vaya: Bala (upto16years)-
Vivardhamana (17-30 yrs.)-
Madhyama (31-60 yrs.)-
Vriddha (More than 60yrs.)-
(C) ASHTAVIDHA PARIKSHA
(i) Nadi Dosha:- Vata / Pitta / Kapha / Vatapitta / Pittakapha / Vatakapha
/ Kapha / Sannipataja

Gati: Manda / Madhya / Teevra Jalouka / Sarpa / Chatak /


Mandooka / Kaka / Hansa
Yati: Sama / Vishama
Samhati: Kathina / Mridu
Aayati: Krisha / Sthoola

(ii) Mutra Matra : Alpa / Bahula / Samanya


Varna: Yellow / Red / Samanya
Gandha : Teevra / Alpa / Samanya
Pravriti: Burning / Painful / Sahaja
Any other findings

(iii) Mala Matra: Alpa / Bahula / Samanya


Varna: Dhoosara / Shveta / Harita / Peeta / Samanya
Gandha: Teevra / Alpa / Samanya
Pravritti : Regular / Irregular
Prakriti : Saama / Nirama
Any other findings:

(iv) Jihva Varna- Rakta / Shyama / Shveta / Peeta / Samanya


Swaroop- Khara / Sphutika / Malavrita / Shushka / Ardra / Samanaya /
Kantakayukta/ Granthi
(v) Shabda: Spashta / Aspashta / Kanthakoojana / AntraKoojana / Sandhi
Sphutana / Gadgada / Sanunasik / Guru / Teekshna / Samanya
(vi) Sparsha (Tvak): Sheeta / Ushna / Anushnasheeta / Mridu / Kathora
Shlakshana / Khara / Sakandu / Samanya
(vii) Drik: Pandutabha / Shwetabha / Sadaha / Sakandu / Shyawa / Samipya
Drishti Dosha / Doora Drishti Dosha / Samanya
(viii) Aakriti: Krisha / Sthoola / Madhyama / Dirgha / Hrasva

SYSTEMIC EXAMINATION:-
(A) Respiratory System

1. Inspection ●Shape of chest-

● Resp. rate-

● Resp. rhythm

● Type of Breathing
● Scars

2. Palpation ● Chest movements

● Mediasternum

● TVF (Tactile vocal fremitus)

● Tenderness
3. Percussion
–
● Dullnote / Resonant / Hyper-resonant
● Shifting dullness
4. Auscultation –
● Breath sounds–
● Any added sounds-
● Others-
(B) CVS–
1) Inspection -Precordium-
2) Palpation -Apex Beat-
- Thrills-
3) Percussion-
4) Auscultation -Heart sounds
- Murmur
(C) Gastro-intestinal System
1)Inspection - Shape of abdomen-
- Umbilicus
- Dilated veins
- Scars
2)Palpation - Tenderness
- Guarding
- Rigidity
- Organomegaly
3)Percussion - Shifting dullness -Horse–shoe shaped dullness
- Fluid thrill -Puddle’s sign
4)Auscultation - Bowel sounds
- Peristaltic soun
(D) CNS
● Cranial nerves:-

● Muscle Power & Tone


Tone:-

Right Left
REFLEXES:-

KNEE JERK-
ANKLE JERK-
TRICEPS JERK-
BICEPS JERK-
RADIAL JERK-
JAW JERK-
CLONUS-
PLANTER REFLEX (BABI
(BABINSKI’SSIGN)-
CORNEAL REFLEX
CORDINATION
ROMBERG’S SIGN
ABDOMINAL REFLEX
REFLEX-

SENSORY EXAMINATION
EXAMINATION-
Touch Pain
Temperature Vibration Sense
(E) MUSCULO SKELETAL SYSTEM-
 Pain & tenderness in joints:-
 Any swelling & temperature difference
 Any joint deformity
 Crepitations
 Restricted movements
(F) UROGENITAL SYSTEM:-

(G) ENDOCRINE SYSTEM:-

3. INVESTIGATIONS:-

4. PROVISIONAL DIAGNOSIS:
5. DIFFERENTIAL DIAGNOSIS:-

6. FINAL DIAGNOSIS

7. TREATMENT:-
8. PATHYA:-
(a) Ahara

(b) Vihara

9. APATHYA
(a) Ahara

(b) Vihara

Signature of the Student Signature of the Teacher

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