S.G.V.V.

Ts

S.J.G Ayurvedic Medical College, Hospital, P.G Studies & Research

Centre, Koppal
P.G. Dept. of Panchakarma
Virechana-Case sheet Proforma
Name:
Age:
Address:
Ph. No:
Complaints if any:

Sl.No:
OPD No:
Date of Initiation:
Date of completion:

Chikitsa Vrittanta:
Vayaktikia Vrittanta:
Dosha:
Agni:
Mala pravritti:
Mutrapravritti:
Vyasana:
Vital examination:
Height:
Weight:
kg
BMI:
mm of Hg
Deepana-Pachana: Trikatu Churna, Matra:
From: to:...
SNEHANA: with
DAYS

I DAY

Koshta:
Rajahpravritti:

Pulse:

/min

Kala:

From: to:...
II DAY

III DAY

IV DAY

Sneha matra
Pana kala
Kshudha
pradhurbhava
kala
Sneha pachana
kala
SNEHA JEERYAMANA LAKSHANA NIRIKSHANA:
Lakshan I DAY
II DAY
III DAY
as
Shiroruk
Bhrama
Murcha
Stheeva
na
Lalasrav
a
Angasa
da
Klama

IV DAY

BP:
Anupana:

Trishna
Daha
Arati

SNEHA JEERNA LAKSHANA NIRIKSHANA:

Lakshanas
I
II day
day
Jeeryamana
Lakshana
prashama
Sharira Laghuta
Vatanulomana
Kshudhapravritti
Trishnapravritti
Udgharashuddhi

III day

Advice during this period:

Ahara:
SAMYAK SNIGDHA LAKSHANA NIRIKSHANA:
Lakshanas
I day II day III day
Vatanulomana
Deeptagni
Purisha
Snigdhata
Asamhata
Varchas
Twak Snigdhata
Anga Laghava
Gaatra
Mardhavata
Snehodhwega
Klama
Shaithilya

IV
day

Vihara:
IV day

BAHYA SNEHANA: Saarvadaihika Abhyanga & Bashpa Sweda; from:.. to:

..
VIRECHANA: with
Matr Kal Anupa Pratham Antima Purisha
Remarks
a
a
na
a Vega
vega
Nirikshana
kala
kala

VIRECHANA KARMA PARINAMA:

Laingiki
Vegik
i

Mana
ki

Antik
i

Shuddhinirnaya

KARYAPHALAM:
Sign. of Person:

PASCHAT KARMA:
Tatkaleena Upachara:
Samsarjana Krama:
Annakala

Sign. of Physician

Bhojana dravya

Matra

Nirikshana