Published by:

Traditional and Complementary Medicine Division (T&CM) Division, Ministry of Health

(MOH) Malaysia, Block E, Jalan Cenderasari, 50590, Kuala Lumpur, Malaysia

Copyright:

The copyright owner of this publication is T&CM Division. Content may be reproduced in any
number of copies and in any format or medium provided that a copyright acknowledgement
to T&CM Division is included and the content is not changed, not sold, nor used to promote
or endorse any product or service, and not used in an inappropriate or misleading context.

ISBN: 978-967-16380-7-1

Available on the following website:

http://tcm.moh.gov.my

STATEMENT OF INTENT

This practice guideline is intended to be a guide for clinical practice on Shirodhara at MOH
healthcare facilities, based on the best available evidence at the time of development.
Adherence to this guideline may not necessarily guarantee the best outcome in every case.
Each healthcare provider is responsible for the management of his/her patient based on the
clinical picture presented by the patient and the availability of treatment at the facility. This
guideline shall be published in the last quarter of 2019 and it shall be reviewed after five
years or when new evidence is available.

Edition published thus far:

1st Edition 2011

Cover designed by:

Traditional and Complementary Medicine Division

 TABLE OF CONTENTS

No. Title Page

GUIDELINE DEVELOPMENT
Objective 5
Method 5
Target Population 5
1. INTRODUCTION
1.1 Overview 6
1.2 Treatment Principles of Shirodhara 7
1.3 Possible Benefits of Shirodhara 7
2. SHIRODHARA SERVICES AT T&CM UNITS IN MOH HOSPITALS
2.1 Referral criteria for Shirodhara 9
2.2 Indications for Shirodhara 9
2.3 Contraindications for Shirodhara 9
3. STANDARD OPERATING PROCEDURE
3.1 Treatment Procedures 11
3.2 General Requirement of the Treatment Room 12
3.3 Equipment 12
3.4 Types of Oils 13
3.5 Treatment Regime 13
3.6 Monitoring Treatment Response/ Assessment Tools 14
4. SAFETY AND ADVERSE EVENTS
4.1 Precautions 15
4.2 Adverse Events 15
4.3 Identification and Reporting of Adverse Events 15

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5. APPENDICES
Appendix 1: Patient Management Flow Chart 17
Appendix 2: Shirodhara Screening Form 18
Appendix 3: Shirodhara Consent Form (Bahasa Melayu) 20
Appendix 4: Shirodhara Consent Form (English) 21
Appendix 5: Shirodhara Clerking Form 22
Appendix 6: Pittsburgh Sleep Quality Index (PSQI) 24
Appendix 7: Ministry of Health Pain Scale (Bahasa Melayu) 26
Appendix 8: Ministry of Health Pain Scale (English) 27
Appendix 9: Depression, Anxiety and Stress Scale – 21 Items (DASS-21) 28
Appendix 10: Report on Suspected Adverse Events, Traditional and 30
Complementary Medicine Division, Ministry of Health
Malaysia

6. GUIDELINES DEVELOPMENT COMMITTEE 33

7. REFERENCES 34

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 GUIDELINE DEVELOPMENT

OBJECTIVE

This practice guideline is the second edition of the T&CM Practice Guideline on Shirodhara.
It has been revised in light of new treatment indications and available evidences since its last
publication. As Shirodhara is a form of T&CM treatment offered at selected Ministry of Health
(MOH) hospitals, a standardised set of treatment criteria and treatment planning schedule
were determined during the revision of this guideline. The standardisation of this practice is
to ensure a safe mechanism for patient referral and to suggest possible outcome
measurement tools to assess its value as a complementary therapy for certain conditions.

METHOD

A literature search was carried out using Pubmed and Cochrane Database of Systemic
Reviews (CDSR). All literatures on Shirodhara therapy regardless of the study design were
included in the literature search. The search was limited to researches published in English
language. The search was conducted from January 2019 to May 2019. A panel consisting of
officers from MOH Malaysia and Ayurvedic physicians deputed by the Government of India
had participated in the development of this practice guideline.

TARGET POPULATION

This document is intended to guide healthcare professionals in the T&CM Units of MOH
hospitals towards safe and effective practice of Shirodhara therapy based on the best
available evidence.

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 1. INTRODUCTION

1.1 Overview

Ayurveda is one of the world’s oldest medical systems and it literally means “knowledge of
life”. It originates from ancient Indian writings that represents a “natural” and holistic
approach towards the healing of physical and mental health.(1)

Based on Ayurvedic philosophy, the entire cosmos consists of five basic elements – Ether,
Air, Fire, Water and Earth. These five elements are grouped into three basic forms of energy
which are known as tridosha. The tridosha (vata, pitta and kapha) are biological energies that
exist throughout the human body and mind which function to govern and regulate all
psychophysiological responses and pathological changes. (2)(3)

Vata is the derivation of the elements of Air and Ether and is translated as the energy of
movement. It regulates the body’s greater life force and gives motion to pitta and kapha, thus
the name of “King of the Doshas”. Physiologically, it governs anything related to movement,
such as breathing, blinking, talking, nerve impulses, movements in the muscles and tissues,
circulation, assimilation of food, elimination, urination, and menstruation. When it is in
balance, vata promotes creativity and flexibility. In the case where it is out of balance, it will
produce fear, anxiety, degeneration and abnormal movements.(2)

Pitta represents the qualities of Fire and Water elements and it is the energy of
transformation, digestion and metabolism in the body. It oversees processes that are related
to conversion and transformation throughout the body and mind by providing the body with
heat and energy via the breakdown of complex food molecules. Psychologically, it provides
the radiant light of the intellect such as understanding and intelligence. However, when it is
out of balance, pitta arouses anger, hatred, jealousy, and inflammatory disorders.(2)

Kapha is principally made up of Earth and Water elements and it is the energy of building
and lubrication that helps to form the physical structure and the smooth functioning of all
the body parts. Physiologically, it moistens food, gives bulk to tissues, lubricates joints, stores

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energy, and relates to cool bodily fluids such as water, mucous, and lymph. Kapha is
expressed as love, calmness, and forgiveness when it is in balance. Greed, possessiveness,
depression and congestive disorders are the results of Kapha’s imbalance.(2)

Shirodhara, as one of the healing techniques of Ayurveda, is characterised by the continuous

pouring, flowing, dripping, spilling of oil or any other liquids such as decoction, medicated
milk, medicated butter milk and water on the forehead for a specific period of time.(4) In
Sanskrit, shiro means “head”, and dhara means “continuous flow in a stream”.(5)

Shirodhara may be performed using different types of oil or liquids as described below:

i. Tail Dhara (using oil)

ii. Takra Dhara (using buttermilk)
iii. Kshira Dhara (using milk)
iv. Kwath Dhara (using decoction)

At present, only Tail Dhara is offered at selected T&CM Units in MOH hospitals.

1.2 Treatment Principles of Shirodhara(2)(4)

The probable mode of action of Tail Dhara is due to its oil action (Snehan Karma) and heat
action (Svedan Karma). It is believed that the oil nature will suppress the vata and pitta dosha
while the heat will eliminate the vata and kapha dosha. The medicinal property of the herbs
contained in the medicated oil may induce a hormone normalising effect on the pituitary
gland. Therefore, relaxation of the body and mind could be achieved through Shirodhara.(6)

1.3 Possible Benefits of Shirodhara

i. Anxiolytic effect
Several clinical studies on healthy volunteers conducted in Japan and India have
indicated that Shirodhara has an anxiolytic effect.(5)(7)
ii. Tranquilising effect

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 There have been studies conducted on patients with insomnia that have
demonstrated significant improvement in patients’ conditions after they have
undergone Shirodhara.(3)(6)
iii. Stress reduction
A number of studies have reported that Shirodhara possess clinical benefits towards
stress aggravation due to chronic degenerative diseases.(8)(9)

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 2. SHIRODHARA SERVICES AT T&CM UNITS IN MOH HOSPITALS

Shirodhara service is currently available in Port Dickson Hospital (since 2012) and Cheras
Rehabilitation Hospital (since 2015). Shirodhara is provided as a complementary therapy
to the standard medical treatment for all the indications stated in this guideline.

2.1 Referral Criteria for Shirodhara

Patients who are referred for Shirodhara should be:

i. 18 years old and above

ii. Clinically stable
iii. Able to understand and follow instructions
iv. Referred by a specialist or a registered medical officer

2.2 Indications for Shirodhara

i. Insomnia(3)(10)(6)
ii. Headache(10)
iii. Stress or mental fatigue(8)(11)(7)
iv. Anxiety(8)(12)(5)(7)
v. Mild depression

2.3 Contraindications for Shirodhara

i. Hypotension
ii. Alcoholism or drug addiction
iii. Psychological disorders (Acute psychosis, suicidal ideation, delirious, mania or
dementia)
iv. Pregnancy
v. Brain tumor
vi. Central or peripheral neuropathy
vii. Peripheral arterial disease

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viii. Head and neck disorders (recent neck injury, presence of an open wound,
inflammation, loss of sensation or acute sinusitis)
ix. Influenza-like illness (ILI)

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 3. STANDARD OPERATING PROCEDURE

Before commencement of Shirodhara, the procedure and the potential side effects or adverse
events that might occur should be explained to the patient. Consent must be obtained before
the therapy is provided.

3.1 Treatment Procedures (13)

Poorva Karma (Pre-Operative Procedure)

 The patient should have food items that are easy to digest, non-oily, less spicy and
warm during the entire treatment course.
 The patient shall try to be as relaxed, stay positive and stress free as possible
throughout the treatment course.
 The patient should avoid from drinking cold water during the treatment course and
lukewarm water is recommended.
 The patient should have meals or food at least two hours before the procedure.
 The patient should relieve any natural urges before commencement of the procedure.
 The therapy shall begin with a massage to the head and neck region for 10 to 15
minutes.

Pradhana Karma (Operative Procedure)

 After completion of the massage, the patient shall lie in a supine position on a Droni-
Abhyangam (an oil massage table which is capable of collecting excess oil) with the
head and neck supported with a roll of towel or a pillow. The patient should be in a
comfortable position.
 Cotton gauze shall be placed over the eyes to protect them from the oil during the
procedure.
 A stream of warm oil is then poured onto the centre of the forehead, between the
eyebrows. This point is considered as the ‘third eye’ or the centre of perception.(5)(7)
 The technical aspects of the procedure are as described below:

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 i. The oil temperature should be maintained at 39°C ± 0.2°C.
ii. The oil flow rate is kept at approximately 300 – 350 ml per minute (the flow
rate depends on oil thickness, quantity used, its temperature and diameter of
the nozzle).
iii. Diameter of the dripping oil nozzle should be 5 x 5 mm to 8 x 8 mm.
iv. The distance between the tip of the oil nozzle and the forehead ranges from 10
- 20 cm.
v. Three litres of oil is used in each Shirodhara session (oil may be collected and
reused on the same patient).
vi. The duration of Shirodhara procedure ranges from 30 to 45 minutes.

Paschat Karma (Post-Operative Procedure)

 After completion of the procedure, the patient is required to rest on the Droni-
Abhyangam for five to ten minutes.
 The patient may take a shower with lukewarm water approximately two hours after
the procedure.
 The patient is advised not to expose themselves to direct sunlight, cold and/ or windy
weather for at least one to two hours by covering their head, ears and neck region
with appropriate clothing.

3.2 General Requirement of the Treatment Room

 The room temperature should be maintained between 22 – 25°C.

 The massage table should be neat, clean, properly cushioned and covered with a
blanket.

3.3 Equipment

 Droni – Abhyangam or oil massage table (able to collect excess oil used during the
procedure) (as in Figure 1).
 Oil collection and heating system with temperature monitoring.

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  Oil collection and filtration system (if the oil is reused in one procedure session).
 Clean towels and linen.

3.4 Types of Oil

For each session of treatment procedure, three litres of oil shall be used and the type of oil
used will depend on the indication of treatment. Currently, three types of oil which are used
at MOH hospitals in Malaysia:

Types of Oil Indication

i. Ashwagandhadi oil - Insomnia
ii. Ksheerbala oil - Stress, anxiety and depression
iii. Dhanvantara oil - Headache

Figure 1: Droni – Abhyangam Figure 2: Dhanvantara oil

3.5 Treatment Regime

Each treatment session should last between 45 to 60 minutes:

i. Massage of the head and neck region - 10 – 15 minutes

ii. Shirodhara - 30 – 45 minutes
iii. Rest after Shirodhara - 5 – 10 minutes

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A complete course of Shirodhara treatment may range from 7 to 14 days depending on
severity of illness. Ideally, it is performed for seven consecutive days. The treatment regime
may be adjusted by the T&CM practitioner depending on each patient’s outcome/ reaction
to the treatment. In order to monitor the patient’s response towards Shirodhara, an
assessment tool for each indication is introduced. The assessment is recommended to be
performed before the initiation of treatment and after a complete course of treatment. It is
also recommended that patients who have completed treatment should be assessed every
two months over a period of six months to evaluate the sustained effect of Shirodhara.

3.6 Monitoring Treatment Response/ Assessment Tools

Indications Recommended Assessment Tools

Insomnia Pittsburgh Sleep Quality Index (PSQI)(Appendix 6)
Headache
i. Migraine Ministry of Health Pain Scale (Appendix 7 & 8)
ii. Tension-Type
Headache

Stress or Mental Fatigue

Depression, Anxiety and Stress Scale – 21 Items
Anxiety
(DASS-21)(Appendix 9)
Depression

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 4. SAFETY AND ADVERSE EVENTS

4.1 Precautions

 The oil temperature should be monitored and maintained at 39°C ± 0.2°C throughout
the procedure.
 Patients should be observed for any sign of complications or distress during the
procedure.
 After the procedure is completed and while the patient is resting on the treatment
bed, any adverse events or complications should be noted and appropriate measures
need to be taken.
 If patient feels any discomfort during the procedure, he/ she should inform the T&CM
practitioner or therapist.

4.2 Adverse Events

Generally, Shirodhara is a safe procedure(3)(5)(6). However, patients may experience some

side effects/ adverse events such as:

i. Discomfort at the occipital region.

ii. Headache and neck pain.
iii. Light-headedness and vertigo from prolonged supine position.
iv. Blisters and burns if the oil used is too hot.
v. Allergic reaction caused by the oil used.
vi. Hypotension.
vii. Numbness in the extremities and low backache due to prolonged supine position.

4.3 Identification and Reporting of Adverse Events

 The patient is advised to report any adverse events to the T&CM practitioner or
medical officer in charge of the T&CM Unit.
 The patient shall be attended to immediately and the adverse event shall be identified
by the T&CM practitioner or medical officer in charge.

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 Adverse event is to be filled in the T&CM Unit’s Adverse Reaction Form and to be sent
to the National Pharmaceutical Regulatory Agency (NPRA).

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 5. APPENDICES

Appendix 1: Patient Management Flow Chart

Start

Referral of patients to T&CM Unit by

specialist or registered medical officer

Appointment given to patient

Screening by medical personnel

Clerking and assessment by T&CM

practitioner

Suitable for Shirodhara?

Yes No

Provision of treatment and Refer back to referring

counseling by therapy specialist or registered
medical officer for other
treatment options

Any Adverse Event?

Yes No

Stop treatment Follow up accordingly

Report on suspected Assessment done

adverse events routinely

Refer to medical officer Discharge

in charge of the T&CM after
Unit or the Accident treatment
and Emergency completed 17 | P a g e
Department
Appendix 2: Shirodhara Screening Form

KEMENTERIAN KESIHATAN MALAYSIA

UNIT PERUBATAN TRADISIONAL DAN KOMPLEMENTARI
HOSPITAL ____________________________

BORANG SARINGAN SHIRODHARA

(SHIRODHARA SCREENING FORM)

To be filled in by a Medical Personnel

Nama / Name: No. KP / NRIC: MRN:

Alamat / Address: Umur / Age: Jantina / Gender:

No. Telefon / Tarikh / Date:

Contact Number:
Masa / Time:
Dirujuk oleh / Referred by:

Diagnosis Pesakit / Patient’s Diagnosis:

Aduan Pesakit / Chief Complaints:

Sejarah Perubatan / Sejarah Pembedahan /

Past Medical History: Past Surgical History:

Darah Tinggi / Hypertension

Kencing Manis / Diabetes Mellitus
Penyakit Jantung / Ischaemic Heart
Disease
Sawan / Epilepsy
Lelah /Asthma
Kanser / Cancer
Lain-lain/ Others: sila nyatakan/please state
______________________________________________________

Sejarah Pengambilan Ubat-ubatan / Medication Alahan / Allergies:

History:

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Keputusan Ujian / Investigation Results:
(sekiranya ada / if available)

TANDA VITAL / VITAL SIGNS

Tekanan Darah / Blood Pressure: Suhu Badan / Temperature:

Kadar Denyutan Nadi / Pulse Rate: Bacaan Gula / Blood Glucose:

(untuk kes DM sahaja / DM patients only)

KONTRAINDIKASI UNTUK SHIRODHARA /

CONTRAINDICATIONS FOR SHIRODHARA

KEADAAN / CONDITIONS YA / YES TIDAK / NO

Tekanan darah rendah/ Hypotension
Ketagihan alcohol atau dadah / Alcoholism or drug addiction
Masalah Psikologi / Psychological Disorders (Acute Psychosis,
suicidal ideation, delirious, mania or dementia)
Mengandung / Pregnancy
Ketumbuhan dalam otak / Brain tumor
Neuropati, terutama kehilangan deria rasa di bahagian kepala dan
leher / Neuropathy, especially loss of sensation over head and neck
region
Peripheral arterial disease
Masalah pada kepala dan leher (Kecederaan, luka atau keradangan
pada bahagian kepala dan leher atau sinusitis akut / Head and neck
disorders (recent neck injury, presence of an open wound,
inflammation or acute sinusitis)
Demam dan selesema akut/ Influenza-Like-Illness (ILI)
Tanda-tanda penyakit lain pada pengetahuan anda/
Any other symptoms known to you

KESESUAIAN UNTUK SHIRODHARA

(SUITABILITY FOR SHIRODHARA)

YA / YES

TIDAK / NO

Tandatangan / Signature:

Nama / Name of Medical Personnel:

Tarikh / Date:

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Appendix 3: Shirodhara Consent Form (Bahasa Malaysia)
Sila baca maklumat ini dengan teliti. Rujuk kepada pengamal anda jika terdapat perkara yang tidak anda fahami.
Apakah Shirodhara? Peringatan berjaga-jaga sekiranya kesan
Shirodhara merupakan satu teknik perawatan sampingan dialami:
Ayurveda atau terapi yang menggunakan minyak Pesakit dikehendaki melaporkan kepada pengamal
suam yang dialirkan ke atas kepala. Ia merupakan perubatan pada kadar segera sekiranya mengalami
salah satu terapi persediaan sebelum rawatan sebarang kesan sampingan semasa atau selepas
Panchakarma dilakukan. rawatan Shirodhara diberikan.

Adakah ianya selamat? Adakah terdapat maklumat-maklumat lain yang

Secara amnya, Shirodhara merupakan satu prosedur perlu dimaklumkan kepada pengamal?
yang selamat. Selain daripada maklumat perubatan yang biasa,
adalah amat penting bagi anda memberitahu
Adakah ianya mempunyai kesan sampingan? pengamal / petugas perubatan sekiranya anda:
Anda perlu mengetahui bahawa anda mungkin
mengalami kesan sampingan yang sementara Sila tanda √ pada kotak yang berkaitan.
berikutan rawatan Shirodhara, antaranya: Ya Tidak
 Pening selepas rawatan; Mengandung
 Sakit di bahagian kepala dan leher ketika Ketagihan alkohol/ dadah
rawatan; Masalah kulit pada bahagian
 Alahan terhadap minyak yang digunakan; kepala dan leher
 Melecur sekiranya suhu minyak yang Kecederaan pada leher
digunakan adalah terlalu panas. Kurang deria rasa terutama di
kepala dan leher
Peripheral arterial disease
Alahan pada minyak/ herba

PERAKUAN KEIZINAN
Saya mengakui bahawa saya telah dimaklumkan dengan terperinci mengenai rawatan tersebut dan saya
faham penjelasan yang telah diberikan. Saya faham bahawa saya boleh bertanya sebarang soalan berkenaan
dengan rawatan yang akan diberikan sebelum saya menandatangani akuan ini. Saya mengaku bahawa
keputusan ini adalah di atas kerelaan diri saya sendiri. Saya akan bertanggungjawab sepenuhnya ke atas
sebarang kemungkinan akibat persetujuan / tindakan saya ini.
Saya mengakujanji tidak akan mengambil sebarang tindakan undang-undang terhadap Kerajaan, pihak
hospital, pengamal atau mana-mana pihak lain yang berkenaan sekiranya berlaku sebarang perkara yang
tidak diingini akibat daripada keputusan saya ini.

PESAKIT/ PENJAGA/ AHLI KELUARGA SAKSI

Tandatangan Saksi: …………………………………

Tandatangan: …………………………………………
Nama Saksi: …………………………………………
Nama Penuh: …………………………………………
No. Kad Pengenalan: ………………………………..
No. Kad Pengenalan: ………………………………..
Hubungan dengan Pesakit: …………………………
PENGAMAL PERUBATAN/ PENGAMAL PT&K Tarikh:
Tandatangan: ………………………………………..
Nama Penuh: …………………………………………

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Appendix 4: Shirodhara Consent Form (English)
Please read the following information carefully. Kindly refer to the practitioner if clarification is required.
What is Shirodhara?
Shirodhara is form of Ayurvedic T&CM treatment What should I inform to the practitioner /
which involves dripping of warm oil over the healthcare staff prior to the treatment?
forehead. It is one of the preparatory therapy before You should let your practitioner/ healthcare staff
the treatment of Panchakarma. know if you are suffering from any medical
conditions such as listed below:
Is it safe?
Shirodhara is regarded as a relatively safe procedure. Please tick (√) the relevant box(es).

Does it have any side effects? Conditions Yes No

Patients should be aware that they may experience Pregnant
the following transient side effects following Alcoholism/ drug addiction
treatment: Skin problem over head and
 Dizziness after treatment; neck region
 Pain over head and neck region during the Neck injury
treatment; Loss of sensation over head
 Allergy reaction towards the oil used; and neck region
 Burns if the oil temperature is too high. Peripheral arterial disease
Allergy towards oil/ herbs
Precautions to be taken in case of any side effects:
Patients should report to medical personnel
immediately in case of any side effects following
Shirodhara treatment.

CONSENT FOR TREATMENT

I declare that I have been informed in detail about the treatment and I understand the explanation given. I
understand that I can ask any questions pertaining to my treatment before signing this form. I have the right
to refuse or discontinue any treatment at any time.
I also consent to such further or other measures as may be found necessary during the course of above
mention treatment.
I understand that no legal action can be taken against the Government, the hospital, the practitioner or any
other parties concerned in the event of any undesirable consequences as a result of my decision.

PATIENT/ LEGAL GUARDIAN/ FAMILY MEMBER WITNESS

Signature: ……………………………………………...
Signature: ………………………………………
Full Name: ……………………………………………..
Name: ……………………………………………
Identity Card Number: …………………………….
NRIC: …………………………………................
Relationship with the Patient: ……………………….

MEDICAL PRACTITIONER/ T&CM PRACTITIONER Date:

Signature: …………………………………………….........................
Full Name: …………………………………......................................

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Appendix 5: Shirodhara Clerking Form

TRADITIONAL AND COMPLEMENTARY MEDICINE UNIT

___________________________________ HOSPITAL

PATIENT INFORMATION
Name: NRIC: Registration No.:

Address: Age: Gender:

Postcode: State: Tel. No: Race:

Referring Physician/ Unit:

VITAL SIGNS
Weight (kg): Blood pressure (mmHg): Temperature (°C):

Height (cm): Pulse rate (per minute):

HISTORY
Chief complaint: Past surgical history:

Past medical history: Treatment history:

Allergy:

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PATIENT ASSESSMENT
Physical examination:

CONCLUSION
Contraindications (Please tick √ at the appropriate box):
YES NO
Hypotension
Recent neck injury, open wound or inflammation at the head
and neck region
Pregnancy
Brain tumour
Sinusitis
Neuropathy (central/ peripheral), especially loss of sensation
over the head and neck region
Peripheral arterial disease
Alcoholism or drug addiction

Suitable for Shirodhara Not suitable for Shirodhara

TREATMENT PLAN
Treatment regime / Duration of treatment:

Practitioner’s name:

Signature: Date:

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Appendix 6: Pittsburgh Sleep Quality Index (PSQI)

Instructions: The following questions relate to your usual sleep habits during the past month
only. Your answers should indicate the most accurate reply for the majority of days and
nights in the past month. Please answer all questions.

1. During the past month, what time have you usually gone to bed at night? ___________

2. During the past month, how long (in minutes) has it usually taken you to fall asleep each
night? _______________________

3. During the past month, what time have you usually gotten up in the morning? __________

4. During the past month, how many hours of actual sleep did you get at night? (This may be
different than the number of hours you spent in bed.) _____________________

5. During the last month, how often Not during Less than Once or Three or
have you had trouble sleeping the past once a twice a more times
because you … month week week a week
a. Cannot get to sleep within 30
minutes
b. Wake up in the middle of the
night or early morning
c. Have to get up to use the
bathroom
d. Cannot breathe comfortably
e. Cough or snore loudly
f. Feel too cold
g. Feel too hot
h. Have bad dreams
i. Have pain
j. Other reason(s), please describe:

6. During the past month, how

often have you taken medicine to
help you sleep (prescribed or “over
the counter”)?
7. During the past month, how
often have you had trouble staying

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awake while driving, eating meals,
or engaging in social activity?
No Only a very Somewhat A very big
problem at slight of a problem
all problem problem
8. During the past month, how
much of a problem has it been for
you to keep up enough enthusiasm
to get things done?
Very good Fairly good Fairly bad Very bad
9. During the past month, how
would you rate your sleep quality
overall?
No bed Partner/ Partner in Partner in
partner or roommate same room same bed
room mate in other but not
room same bed
10. Do you have a bed partner or
roommate?
Not during Less than Once or Three or
the past once a twice a more times
month week week a week
If you have a roommate or bed
partner, ask him/ her how often in
the past month you have had:
a. Loud snoring
b. Long pauses between breaths
while asleep
c. Legs twitching or jerking while
you sleep
d. Episodes of disorientation or
confusion during sleep
e. Other restlessness while you
sleep, please describe:

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Appendix 7: Ministry of Health Pain Scale (Bahasa Melayu)(14)(15)(16)

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Appendix 8: Ministry of Health Pain Scale (English)(14)(15)(16)

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 Appendix 9: Depression, Anxiety and Stress Scale – 21 Items (DASS-21)(17)
SOAL SELIDIK DASS
Nama: Tarikh:
Langkah 1: Sila baca dan jawab soal selidik DASS.
Langkah 2: Masukkan skala markah jawapan ke dalam ruangan kosong di bahagian 2, mengikut Soalan (S) bagi setiap kategori (Stres,
Anzieti dan Kemurungan).
Langkah 3: Jumlahkan skala markah bagi setiap kategori bagi mengetahui tahap status kesihatan mental anda.
Langkah 4: Sila isikan keputusan dalam bahagian 3 dan isikan dalam keratan di muka hadapan.

BAHAGIAN 1
Sila baca setiap kenyataan di bawah dan bulatkan jawapan anda pada kertas jawapan berdasarkan jawapan 0, 1, 2 atau 3 bagi
menggambarkan keadaan anda sepanjang minggu yang lalu. Tiada jawapan yang betul atau salah. Jangan mengambil masa yang terlalu lama
untuk menjawab mana-mana kenyataan.
Please read each statement and circle number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week. There
are no right or wrong answers. Do not spend too much time on any statement.

0 = Tidak Langsung menggambarkan keadaan saya 2 = Banyak atau kerapkali menggambarkan keadaan saya
Did not apply to me at all Applied to me to a considerable degree, or a good part of time
1 = Sedikit atau jarang-jarang menggambarkan keadaan saya 3 = Sangat banyak atau sangat kerap menggambarkan keadaan saya
Applied to me to some degree, or some of the time Applied to me very much, or most of the time

1. Saya dapati diri saya sukar ditenteramkan 0 1 2 3

I found it hard to wind down
2. Saya sedar mulut saya terasa kering 0 1 2 3
I was aware of dryness of my mouth
3. Saya tidak dapat mengalami perasaan postif sama sekali 0 1 2 3
I couldn’t seem to experience any positive feeling at all
4. Saya mengalami kesukaran bernafas (contohnya pernafasan yang laju, tercungap-cungap 0 1 2 3
walaupun tidak melakukan senaman fizikal)
I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence
of physical exertion)
5. Saya sukar untuk mendapatkan semangat bagi melakukan sesuatu perkara 0 1 2 3
I found it difficult to work up the initiative to do things
6. Saya cenderung untuk bertindak keterlaluan dalam sesuatu keadaan 0 1 2 3
I tended to over-react to situations
7. Saya rasa menggeletar (contohnya pada tangan) 0 1 2 3
I experienced trembling (e.g. in the hands)
8. Saya rasa saya menggunakan banyak tenaga dalam keadaan cemas 0 1 2 3
I felt that I was using a lot of nervous energy
9. Saya bimbang keadaan di mana saya mungkin menjadi panic dan melakukan perkara yang 0 1 2 3
membodohkan diri sendiri
I was worried about situations in which I might panic and make a fool of myself
10. Saya rasa saya tidak mempunyai apa-apa untuk diharapkan 0 1 2 3
I felt that I had nothing to look forward to
11 . Saya dapati diri saya semakin gelisah 0 1 2 3
I found myself getting agitated
12 . Saya rasa sukar unutk relaks 0 1 2 3
I found it difficult to relax
13 . Saya rasa sedih dan muring 0 1 2 3
I felt down-hearted and blue
14. Saya tidak dapat menahan sabar dengan perkara yang menghalang saya meneruskan apa yang 0 1 2 3
saya lakukan
I was intolerant of anything that kept me from getting on with what I was doing
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15. Saya rasa hampir-hampir menjadi panik/ cemas 0 1 2 3
I felt I was close to panic
16. Saya tidak bersemangat dengan apa jua yang saya lakukan 0 1 2 3
I was unable to become enthusiastic about anything
17. Saya rasa tidak begitu berharga sebagai seorang individu 0 1 2 3
I felt I wasn’t worth much as a person
18. Saya rasa saya mudah tersentuh 0 1 2 3
I felt that I was rather touchy
19. Saya sedar tindakbalas jantung saya walaupun tidak melakukan aktiviti fizikal (contohnya 0 1 2 3
kadar denyutan jantung bertambah, atau denyutan jantung berkurangan)
I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate
increase, heart missing a beat)
20. Saya berasa takut tanpa sebab yang munasabah 0 1 2 3
I felt scared without any good reason
21. Saya rasa hidup ini tidak bermakna 0 1 2 3
I felt that life was meaningless

BAHAGIAN 2
Panduan Mengira Skor :-
Masukkan skala markah jawapan bagi soalan (S) bagi setiap kategori.
STRES
Soalan S1 S6 S8 S11 S12 S14 S18 Jumlah
Markah
ANZIETI
Soalan S2 S4 S7 S9 S15 S19 S20 Jumlah
Markah
Kemurungan (Depression)
Soalan S3 S5 S10 S13 S16 S17 S21 Jumlah
Markah
Selepas dijumlahkan, sila rujuk kepada petak skor saringan dan terjemahkan jumlah skor untuk
mengetahui tahap status kesihatan mental anda.
SKOR SARINGAN
Kemurungan Anzieti Stres
Normal 0-5 0–4 0–7
Ringan 6–7 5–6 8–9
Sederhana 8 – 10 7–8 10 – 13
Teruk 11 – 14 9 – 10 14 – 17
Sangat Teruk 15 + 11 + 18 +

BAHAGIAN 3
Isikan keputusan (normal, ringan, sederhana, teruk atau sangat teruk) dalam jadual di bawah.
KEPUTUSAN UJIAN DASS
Ujian Tahap
Stres
Anzieti
Kemurungan
SKOR DASS

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Appendix 10: Report on Suspected Adverse Events of Traditional and Complementary
Medicine Division, Ministry of Health Malaysia (Adapted from the Report on
Suspected Adverse Drug Reactions National Centre for Adverse Drug Reactions
Monitoring)

A. PATIENT DETAILS
Name: NRIC:

Age: Contact no.:

 Malay  Others :
 Chinese ___________
 Indian
 Male
Gender Ethnic group  Orang Asli
 Female
Pribumi
Sarawak
 Pribumi Sabah

Past Surgical History:

Past Medical History:

Hypertension

Diabetes Mellitus

Heart Disease

Epilepsy

Asthma

Cancer

Others…………………………………

Medication History: Latest Investigations Results:

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Known Allergies: *if any Treatment Modality:
 Urut Melayu  External Basti
 Postnatal  Shirodhara
 Acupuncture  Herbal Therapy

B. ADVERSE EVENT INFORMATION

Adverse event date:

Description of event:

Time to onset mins/hours/days/months/years Date start of adverse event:

of reaction: (please circle)

Date end of adverse event:

Extent of  Mild Seriousness  Life threatening

reaction:  Moderate of reaction:  Caused or prolonged
 Severe hospitalization
 Caused disability or
incapacity
 N/A (not serious)

Treatment of adverse reaction & action taken:

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Outcome:  Recovered fully
 Recovering
 Not recovered
 Unknown
 Fatal

Date & Cause of death: ............................

Treatment-  Certain
Reaction  Probable
Relationship:  Possible
 Unlikely

 Unclassifiable

C. REPORTER DETAILS

Name: Institution name & address:

Designation: Contact no.:

Email address: Date of report:

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 6. GUIDELINE DEVELOPMENT COMMITTEE

Traditional and Complementary Medicine (T&CM) Division, Ministry of Health

Malaysia:

i. Dr. Goh Cheng Soon (Advisor) ii. Dr. Jaspal Kaur A/P Marik Singh
Director Head of T&CM Practice Section

iii. Dr. Gan Fen Fang iv. Dr. Adilla Nur Binti Halim
Senior Principal Assistant Director Principal Assistant Director
T&CM Practice Section T&CM Practice Section

v. Suraya Hani Binti Sharon

Senior Principal Assistant Director
T&CM Practice Section

Traditional and Complementary Medicine Units, Ministry of Health Malaysia:

i. Dr. Vijay Kumar Srivastava ii. Dr. Hariniramya Gopalachoodamani

Ayurveda Practitioner Ayurveda Practitioner
Cheras Rehabilitation Hospital and Cheras Rehabilitation Hospital and
Port Dickson Hospital Port Dickson Hospital

iii. Dr. Radzuan Bin Mat Ibrahim iv. Dr. Nur Syamimi Binti Mohd Jani
Head of T&CM Unit Head of T&CM Unit
Cheras Rehabilitation Hospital Port Dickson Hospital

v. Muhammad Fariduddin Bin Razali

Medical Assistant
Port Dickson Hospital

Internal Reviewer: Ng Angeline

Head of Policy and Development Section
T&CM Division

External Reviewer: Dr. Norliza Che Mi

Head of Department
Department of Psychiatry
Kajang Hospital

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 7. REFERENCES

1. Ayurvedic Medicine: In Depth [Internet]. National Center for Complementary and

Integrative Health. 2019. Available from:
https://nccih.nih.gov/health/ayurveda/introduction.htm

2. Lad VD. Textbook of Ayurveda - Fundamental Principles of Ayurveda Volume One.

The Ayurvedic Press; 2002. 25-31 p.

3. Vinjamury Sivarama Prasad, Vinjamury Manjusha, Martirosian Claudia der MJ.

Ayurvedic Therapy (Shirodhara) for Insomnia: A Case Series. Glob Adv Heal Med.
2014;3(1):75–80.

4. Polepally DY. Clinical Panchakarma. Jaya Publications; 2008. 15-17 p.

5. Kazuo Uebaba, Feng-Hao Xu, Hiroko Ogawa, Takashi Tatsuse, Bing-Hong Wang,
Tatsuya Hisajima SV. Psychoneuroimmunologic Effects of Ayurvedic Oil-Dripping
Treatment. J Altern Complement Med. 2008;14(10):1189–98.

6. Vasant Patil, Yogesh Godkar, Sanjay Gupta, K.C. Das DBK. Clinical Study on Effect of
Different Methods of Shirodhara in Patients of Insomnia. Int J Ayurveda Pharma Res.
2017;

7. Kalpana D. Dhuri, Prashant V. Bodhe ABV. Shirodhara: A Psycho-Physiological Profile

in Healthy Volunteers. J Ayurveda Integr Med. 2013;4(1).

8. Chittaranjan Kundu, V.D. Shukla, M.A. Santwani NNB. The role of psychic factors in
pathogenesis of essential hypertension and its management by Shirodhara and
Sarpagandaha Vati. An Int Q J Res Ayurveda. 31(4):436–41.

9. Leslie F. Stress Management through Shirodhara. California College of Ayurveda.

10. Pratibha ASP. Management of Essential Hypertension Through Shirodhara

(Tailadhara). Int Ayurvedic Med J. :279–84.

11. Saraswati Devi DSK. Role of Yoga-nidra and Shirodhara on Hypertensive Patients. Int
J Yoga Allied Sci. 4(1).

12. Sanjeev Rastogi AN. Effects of Shirodhara in Generalized Anxiety Disorder. Humanit
Med. 2016;6(4).

13. Gandhidas Sonajirao Lavekar, Ota Sarada, Madan Mohan Sharma VB. A Practical
Handbook of Panchakarma Procedures. Central Council for Research in Ayurveda
and Siddha, Department of AYUSH, Ministry of Health and FamilyWelfare,
Government of India; 2009. 64-65 p.

14. Division T and CM. Consensus Meeting on Improvement Strategy in Traditional and

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 Complementary Medicine (T&CM) Services in Integrated Hospital with T&CM
Practitioners. In 2009.

15. Pain_Scale_(Ruler)_Template_Ver._2018NEW_(2).pdf.

16. Malaysia M of H. Garis Panduan Program Bebas Kesakitan. Ministry of Health

Malaysia; 2018.

17. Malaysia M of H. Borang Saringan DASS. Garis Panduan Modul Unit Kesihatan Mental.

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