DEPARTMENT OF ROGA NIDAN

SAM COLLEGE OF AYURVEDIC SCIENCES &

HOSPITAL, RAISEN
Short case sheet
Patient Name: Case No:
Age: Sex: M / F Date of Admission:
Religion: H / M / S / Ch Date of Discharge:
Marital Status: M / U M / D / W OPD / IPD:
Education: U E / P / M / H / G / P G / Ward / Bed No:
Doctoral / Prof.
Occupation: Consultant:
Socio Economic Status: V P / P / L M / Provisional Diagnosis:
M/UM/R/VR
Address: Final Diagnosis:

MUKHYA VEDANA (Chief Complaints):

On Examination:
1. Pulse
2. Blood Pressure
3. Temperature
4. Weight
5. Icterus
6. Pallor
7. Cyanosis
8. Clubbing
9. Respiratory Rate
10. Heart Rate
11. Oedema
ASTASTHANA PAREEKSHA:
1. Nadi
2. Mala
3. Mutra
4. Jivha
5. Shabda
6. Sparsh
7. Drik
8. Akriti
Systemic Examination:

Management

Signature of the Student

Signature of the Teacher