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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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