Central Council of Indian Medicine: CCIM MD Ayurved - Swasthavrita Syllabus
Central Council of Indian Medicine: CCIM MD Ayurved - Swasthavrita Syllabus
Central Council of Indian Medicine: CCIM MD Ayurved - Swasthavrita Syllabus
Annexure ‘A’
PROFORMA
(Non - Communicable Disease case)
A] General Information :
1. Name of the Patient: ____________________________________________________
2. Age : ___________yrs. 3. Sex : Male/Female 4.Religion : _________
5. Date of Admission : _____________________________________________________
6.Address : ______________________________________________________________
7. Occupation : _____________________ 8. Education : __________________________
9. Per Capita income : _____________________Rupees.
10. Socio economic class (Modified______________)
B] Present illness:
Chief complaints (chronological order) : ________________________________________
C] History of past illness :
1. Similar complaints in past : ________________________________________________
2. Any other significant history : ______________________________________________
D] History of illness in Family :
1. Type : __________________ 2. Composition : ________________________
3. Similar illness in family : Yes /No If yes, give details : _____________________
E] Life Style and personal history :
1. Occupation : Manual Work /Table Work/ Field Work/ Administration /Any other (Specify)
2. Muscular exertion (occupational / domestic etc.) Minimum / Moderate /Heavy
3. Exercise: Nil / Walking / Running / Jogging/ Cycling / Swimming / Weight Lifting/
Anyother specify ___________________________________________________________
4. Mental Stress &Strain : Occupational/ domestic/ any other specify ________________
5. Hobby , Recreation : ____________________________________________________
6. Diet :
a. Veg / Non Veg / Mixed
b. Total calorie intake __________________calorie /day
adequate / inadequate/ excess
c. Fat :
adequate / inadequate/ excess
Vegetable / Animal fats
Predominantly saturated / unsaturated
d. Spice & Hot foods (Specify)
Date :-
PROFORMA
(Communicable Disease case)
A] General Information :
1. Name of the Patient : ________________________________________________
2. Age : ____________________________yrs. 3. Sex : Male / Female
4. Date of Examination : _______________________________________________
5.Address : : _______________________________________________
6. Locality : Urban – Slum / Non-Slum /Rural/Other (Specify) _______________________
7 Duration of Stay in the Locality ; ________________________________(years/months)
8. Hospital Registration No. : _________________ 9. Date of Admission : ____________
10. Religion / Caste : ________________ 11. Education : _________________________
12. Occupation : ___________________ 13. Type of Family : _____________________
14. Total No. of Family Members : ______ 15. Total Family income: _________________
16. Per Capita income per month : ________________________________________Rs.
17. Socio-economic Status (As per _________classification) : ______________________
B] Chief Complaints (In Chronological order)
1. _____________________________________________________________________
2. _____________________________________________________________________
3. _____________________________________________________________________
4. ______________________________________________________________________
C] H/O Present illness : _________________________________________
D] H/O Past illness : __________________________________________
i. Similar complaints in past : __________________________________________
ii. Any other significant history : __________________________________________
E] History of illness in the family : __________________________________________
F] Personal History
a. Dietary : __________________________________________
b. Immunization : __________________________________________
c. Habits : __________________________________________
G] Environmental history (Pertinent to the route of transmission)
i] Water Supply ii] Excreta Disposal iii] Drainage iv] Cattle
v] Pet animals, Poultry vi] Housing condition vii] Over Crowding
viii] insect nuisance ix] Courtyard of house etc.
H] Epidemiological information (Backward tracing of index case.)
i. Any similar case in the family / neighborhood / School / Place of recreation / any other
Specify. ________________________________________________________________
ii. History of attending to similar case – if yes, when ? _____________________________
iii. History of visiting any unaccustomed place if yes, When ? _______________________
iv. Total contacts ____________________v. High risk contacts. ____________________
I] Provisional Diagnosis ( with justification in brief) __________________________
J] Differential Diagnosis : _____________________________________________
1. _____________________________________________________________________
2. _____________________________________________________________________
3. _____________________________________________________________________
4. _____________________________________________________________________
5. _____________________________________________________________________
K] Investigation Done :
_____________________________________________________
a. If yes, reports & your comments. ___________________________________________
b. Other investigations required (with reason) if any. _______________________________
L] Final Diagnosis : _______________________________________________________
M] Management of Patients :
Date :-
PROFORMA
(Ante-natal case)
A] General Information :
1) Date of Examination : ____________________________________________________
2) Name : _______________________________________________________________
3) Age : _________________ yrs.
4) ANC Registered : Yes/No If yes, place/date/month of registration _________________
5) Education of pt __________________ Occupation of pt _______________________
6) Education of Husband ____________ Occupation of Husband __________________
7) No of family members _____________ Total family income ______________Rs/month
8) Socio-economic class ____________ (as per Modified_____________classification)
9) Address : _____________________________________________________________
B] Complaints – if any: __________________________________
C] Menstrual History :Menarche, cycles-day/month, regularity, flow etc.
L. M. P _______________________ E.D.D. _________________________
D] Obstetric History :
Gestational
Age (wks)
Type of
Delivery
Hosp./
Home
Conducted
By
Baby alive/stillborn/ abortion
Live birthinterval
Use of contraceptives(specify)
1.
2.
E] Family History :
___________________________________________________
F] Past History : Hypertension/ Diabetes/ S.T.D./T.B./Leprosy etc.
G] Personal History : Bowel/Bladder/Sleep/Appetite/Habits/Addictions etc.
Immunization status : Tetanus toxoid / Any other ( specify)
a) For current pregnancy
_________________________________
b) For previous pregnancy
________________________________
Nutritional status (based on Calorie Intake, other nutrients, anthropometry etc.)
H] General Examination :
· Height _______________Cms./ Wt. _____________kgs, / TPR / B.P_________mm of Hg
· Pallor/Icterus/ Cyanosis/Oedema/ Lyphadenopathy. any other ( specify)
· Cleanliness of : Skin /Nails/Hair/Clothes/Eyes/Ears/Nose/Oral Cavity / breasts & Nipples
etc.
I] P/A Examination:
· Ht. of uterus/presentation and lie of foetus /Head-floating or engaged/foetal
movements/FHS/ Any other (specify) __________________________________________
J] Systemic Examination:
RS/CVS/CNS ______________________________________________________
K] Investigations: - Urine: Albumin/sugar/microscopic/culture.
- Hb % Blood grouping & cross matching/VDRL/HIV/Blood Sugar
- Any other ( specify) ___________________________________
Date :-
PROFORMA
MALNUTRITION CASE ( UNDER FIVE YEARS AGE )
A] General Information :
i..Date of Examination : ____________________________________________________
ii.. Name of the informer & his/her relationship with the child (case)
1. Name of the child : ______________________________________________________
2. Date of birth : ________________3.Age : _______________4.Sex : Male/Female
5. Caste /Religion : _____________________________________________________
6. Address : _____________________________________________________
7. Whether the child is attending Balwadi/Nursery etc. :____________________________
8. Father __________________________Mother________________________________
I. Name : _______________________________________________
II. Age : _______________________________________________
III. Education : _______________________________________________
IV. Occupation : _______________________________________________
V. Income : _______________________________________________
9. I Total number of family members and family composition ____________________
II. Total family income _________________________________Rupees per month
III. Per Capita Income _________________________________Rupees per month
IV. Socio economic Status _________________ as per ___________classification
B] C omplaints (if any) : _________________________________________
C] History of Present illness : __________________________________________
D] History of Past illness (if any) : __________________________________________
E] Family history : _________________________________________
F] Birth history of the case : _________________________________________
i. Place of delivery : Home/ Hospital /Other (Specify) _____________________________
ii. Delivery conducted by : Untrained or trained Dai / Nurse / Doctor etc. ______________
iii. Type of delivery : FTND/ Pre mature/SFD/Assisted delivery etc. __________________
iv. Congenital anomaly : if any give details. _____________________________________
G] Anthropometry
i. Weight : _____________________Kgs. ii. Height _________________________Cms.
iii. Chest Circumference _________ Cms. Iv. Head Circumference ______________Cms
iv. Mid arm Circumference _______Cms.
H] Immunization History
i. B.C.G./ OPV/ DPT/Measles/Any other give details ______________________________
ii. Immunization card available : Yes / No.
I] Dietary History
i. Breast feeding : Yes/ No
a. If yes : Only breast feed or weaning started
b. If weaned : Age at weaning, type of weaning foods etc.
c. If not breast feed : At what age breast feeding stopped? (give reason if any)
ii. a. Total calorie intake __________________________Calorie /day
b. Total Protein intake __________________________gram/day
iii. Calorie / Protein deficient if any : Yes/No.
If yes mention percent of deficient _______________________________________
iv. Any other nutritional deficiency (Specify) _____________________________________
J] General Examination :
1) Built, nourishment & general appearance
2) TPR 3) Pallor 4) Icterus 5) Cyanosis 6) Lymphadenopathy
7) Oedema 8) Dehydration 9) Eyes 10) Ears
11) Face, Nose, Lips & Tongue 12) Teeth gums oral cavity 13) Skin, nails hair
14) Rachitic changes. 15) Any other (specify)
K] Systemic Examination :RS/CVS/PA/CNS/Gonads
L] Milestones of growth & development
PROFORMA
PathyaApathya, RutuShodhan, Yoga &Nisargopachar Advice to Patients of Attached Hospital.
A) General Information :-
1) Sr. No. : ____________________________________________
2) Name of the Patient : ____________________________________________
3) Address : ____________________________________________
4) OPD No. : ___________________IPD NO. __________________
5) Diagnosis : ____________________________________________
6) Date of Advice : ____________________________________________
B) A dvice given
a) Pathya - Apathya
i. Ahar : _________________________________________________
ii. Vihar : _________________________________________________
b) RutuShodhanUpakrama :
_____________________________________________
c) Yogopachar: _________________________________________________
d) Nisargopachar: _________________________________________________
C) D ate of follow up : _________________________________________________
_________________________________________________
_________________________________________________
D) Remarks: _________________________________________________
________________________________________________
Sign.of Student Sign. of
Guide
Date :-
HEALTH SURVEY
Telephone no.
Family profile
Family Structure
Family Composition
Socioeconomic Class
Birth:
Adoption:
Marriage/Divorce:
Education:
Occupation:
Living condition:
Social relationship:
Socioeconomic status:
1 .Name of disease:
If yes, specify:
SIGN OF STUDENT
SIGN OF GUIDE
Reference Books
Reviewed by
1. Dr. Kamalesh Sharma (Chair person)
2. Dr. Arpan Bhatt
3. Dr. Medha Kulkarni