STANDARDISED CASE FORMAT

Preliminary data:
Date:
Name of the patient:
Sex:
Age:
Occupation:
Qualification:
Religion:
Address:

Chief Complaint:
No Location Sensation Modality Concomitant

Physical Generals:
Appetite:
Cravings:
Aversions:
Thirst:
Sleep:
Dreams:
Stools:
Urine:
Perspiration:

Obs/Gyn history:
Menarche:
Duration: Cycle:
Quantity:
Stain: Character: Color:
Manifestations Before/During/After menses.
Leucorrhoea:
Menopause:
Obs H/o: Delivery/ Abortion/Peurperium.

Thermal and General Reaction:

Summer Monsoon Winter
Fanning
Bathing
Covering
Reaction to External environment: Light/Noise/Touch/Odor etc.
Past History:
Drug Allergy/Interaction H/o.

Family History:

Mental Generals:
Life space, Disposition, State and Expression of the patient.

General Physical Examination:

Pallor: Clubbing:
Icterus: Edema:
Cyanosis: Lymph Nodes:
Tongue:
Pulse: Blood pressure:
Temperature: Respiratory rate:

Systemic Examination:
R.S:
C.V.S:
P/A:
GUS:
C.N.S.:

Local Examination relevant to the case:

Investigations:

Differential Diagnosis:

Diagnosis of the Disease:

Diagnosis of the Miasm: Fundamental:

Dominant:

Prescription:
Date Prescription

Follow-ups:
Date Symptoms Prescription