Post on 11-Feb-2018
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Gampaha Wickramaarachchi Ayurveda Institute
University of Kelaniya
Yakkala
Research Performa for PGD in Shalya antra
itle !
"ame of the Scholar !
"ame of the Supervisor !
#$ "ame of the patient!
%$ Address of the patient!
&$ A'e! ($P$D)I$P$D "o!
*$ Gender!
a$ +ale
,$ -emale.$ ele$ "o!
/$ 0ducation
1$ +arital status!
a$ Sin'le,$ +arriedc$ Separated
2$ (ccupation
3$ 4hief complaints 5 duration
#6$(ther complaints 5 duration
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##$7istory of present illness
a$ (nset8 Insidious Gradual Acute,$ A''ravatin' factorsc$ Re leavin' factorsd$ 4ourse of the disease
Pro'ressive Relapsin' Stationary#%$Past medical history
#&$-amily history-ather 9rother+other Sister
#*$reatment history
reatedAyurveda Allopath 7omeopathyDuration
Untreated
#.$Personal history Ahara
Dietory ha,its
Rasa sathmya
o +adura Amla :avana
o Katu Katu ikhta
Koshta
o +rudu +adya Krura
9o;el
o Re'ular Irre'ular 4onstipated
o -recessive
o -reiety ension
Depression
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Sentimental
"ormal
Se>ual ,ehavior !
:ess seeker
+edium seeker
Stron' seeker
-ood aller'y
Dru' aller'y
"idra ! Good
Interrupted
#/$Past sur'ical history
"um,er of sur'eries "ature of sur'ery
Anesthesia procedure
4omplication of sur'ery
Procedure of sur'ery
#1$"idana
Ahara@a
Sni'dha Ruksha Ati'uru
Rasavishesh@a
+adura Amla :avana
Katu iktha
Kashaya
ihara@a"ishcheshta Ati@a'arana Atikroda
Diva s;apa e'asandaranaAatishramaAti nidra
#2$Ro'i ,ala pariksha#3$
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