Clinical Case Sheet
1. Patient’s No :
2. Name :
3. Age :
4. Sex : Male Female
5. Address :
6. Religion : Hindu Christian Muslim Others
7. Marital status : Married Widowed Unmarried
8. Domicile : Urban Rural
9. Occupation : Business Manual labour Office staff
House wife O thers
10. Educational status : Illiterate Primary school High School
College
11. Income per Month : < 500 500-2000 2000-5000 > 5000
12. Socio Economic Status : Poor Middle class Rich
Presenting complaints Duration
Where is the pain?
(ii) How intense is the pain?
(iii) Description of the pain (e.g. burning,
aching, stabbing, shooting, throbbing, etc).
(iv). How did the pain start?
(v) What is the time course of the pain?
(vi) What relieves the pain?
(vii) What aggravates the pain?
(viii) How does your pain affect
(a) Your sleep?
(b) Your physical functions?
(c) Your ability to work?
(d) Your economy?
(e) Your mood?
(f ) your family life?
(g) Your social life?
(h) Your sex life?
(ix) What treatments have you received?
Effects of treatments?
Any adverse effects?
(x) Are you depressed?
(xi) Are you worried about the outcome of
your pain condition and your health?
(xii) Are you involved in a litigation or
compensation
List of M-JOA
Item Grade/Classification Score BT AT
Subjective symptoms
Lumbar and leg pain No 0
Mild pain or occasional moderate pain 1
Usual moderate pain or occasional severe 2
pain
Frequent or continuous severe pain 3
Numbness No 0
Occasional 1
Frequent but relief may be on their own 2
Continuous, not alleviated 3
Objective signs
Paravertebral No 0
tenderness
Mild 1
Moderate 2
Severe 3
Myodynamia Grade V 3
Grade IV 2
Grade III 1
Item Grade/Classification Score BT AT
Grade 0 to II 0
Straight let raising > 70°, straight leg drive up (-) 0
test
> 45°, straight leg drive up (+) 1
> 30°, straight leg drive up (+) 2
< 30°, straight leg drive up (+) 3
Radiating pain No 0
Hip/thigh 1
Shank 2
Foot 3
Activities of daily life
and work
Stoop and lift heavy Normal stoop, lift weight > 3 kg 0
things
Able to stoop, lift weight ≤ 3 kg 1
Unable to stoop 2
Serious difficulties in bending and lifting 3
Walking Walking ≥ 1 km or 60 min 0
distance/time
Walking ≥ 500 m or 30 min 1
Walking ≥ 100 m or 10 min 2
Serious difficulties in walking 3
Daily time in bed(h) < 10 0
10 to 12 1
12 to 16 2
> 16 3
Ability to work Full-time to do as before 0
Although able to work, occasionally need a 1
break
Although able to work, usually need a break 2
Unable to work 3
Maine-Seattle Back Questionnaire BT AT
I change position frequently to try and get my back or leg
1
comfortable.
2 Because of my back problem, I use a handrail to get upstairs.
3 I get dressed more slowly than usual because of my back problem
or leg pain(sciatica)
I only stand for short periods of time because of my back problem
4
or leg pain
5 Because of my back problem, I try not to bend or kneel down.
I find it difficult to get out of a chair because of my back problem
6
or leg pain(sciatica)
7 My back or leg is painful almost all the time.
8 I sleep less well because of my back problem.
I stay in bed most of the time because of my back or leg pain
9
(sciatica).
10 Because of my back problem, my sexual activity is decreased.
I keep rubbing or holding areas of my body that hurt or are
11
uncomfortable.
12 Because of my back problem, I am doing less of the daily work
around the house than I would usually do
History of Present illness
History of previous illness
Menstrual History
Treatment History
Family History
Personal history
General Examination
Temperature :
Pulse rate :
Respiratory rate :
BP :
Height :
Weight :
Systemic Examination
Cardio vascular System
S1 S 2
Respiratory System
Breath sounds
Rhonchi crepts
Nervous System
Knee reflex Sensory
Ankle jerk Muscle tone
Gastrointestinal System
Appetite
Bowels – loose stools/ normal/ constipated
Urogenital system
Urine freequency
Colour
Loco motor System
Movements of other joints
Dasavidha Pareeksha
Dooshyam : Dosham V/ P/ K
Dhathu
Malam
Desam : Rogam
Rogi
Balam : Rogam
Rogi
Kalam : Kshanadi
Vyadhyavastha
Analam : Abhyavaharana sakthi
Jarana sakthi
Prakrithi : V P K
KP V K VP S ama
Vayah ala
:B Yuva Vridha
Satwam ravaram
:P Madhyam Avaram
Satmyam : Eka rasa rirasa C hatur rasa
Dwi rasa T
Pancha rasa Sarva rasa
Aharam :
Investigations BT AT
Diagnosis
Name of the drugs :
