Post Graduate Department of Kaya Chikitsa

Research Proforma

POST GRADUATE DEPARTMENT OF KAYA CHIKITSA

STATE AYURVEDIC COLLEGE & HOSPITAL

LUCKNOW (U.P.)

Research Proforma for Ph.D

Title: “Clinical Study to Evaluate the Efficacy of some Herbomineral compounds and Vaitaran Basti in cases of Aamvata with Sero-Positive cases of Rheumatoid Arthritis”

INVESTIGATORS

State Ayurvedic College & Hospital, LUCKNOW(U.P.)

Patients consent for the clinical trial

I...... exercise my free favour choice, hereby given my consent to be treated with------. I have been informed to my satisfaction by the attending physician about the purpose of clinical trial and the nature of drug treatment and follow up including the laboratory investigations to monitor and safe guard my body functions.

Signature of Attending Physician Signature of Patient

Date:

(1)PARTICULARS OF PATIENT

Name : / Sr.No. :
Address / Group :
Age / Sex :_____yrs. Male / Female / O.P.D. No. :
Religion : H / M/ S / Ch / J / I.P.D. No. :
Marital Status : M / UM / D / W / Ward/bed No. ;
Education : Un / E /P / M / HS / G /P / / D.O.A. :
Occupation : / D.O.D. :
Socio-eco. Status : VP / LM / M / UM/ R / Diagnosis
Habitat : U / R / SU / Result : Cure / MI / I / UL / LAMA
Desha Jangal/ Anoopa/ Sadharana / Follow up : Recurrence Y / N

(2) CHIEF COMPLAINTS WITH DURATION ( Savadhi Pradhana Vedana )

Sr. No. / Symptoms / Duration
1. / B.P.
2. / Akshiraga
3. / Raktapitta
4. / Santapa,Krodhaprachurata, Feeling of tension
5. / Bhrama
6. / Shirahashula
7. / Klama, Arati
8. / Anidra/Alpanidra/Tandra/ Buddhi Sanmoha/
Mada/ Tamahadarshana
Blood Pressure / SBP and DBP

Sitting

Supine

(3) HISTORY OF PRESENT ILLNESS : ( Vedana Samutpatti Krama )

Onset Sudden / Insidious / Acute / Chronic / Irregular

Course Continuous / Intermittent / Occasional

(4) PAST HISTORY (Purva Vyadhi Vrittanta )

Atherosclerosis / O.C.P. / Renal diseases / Hyperparathyroidism / Coarctation of

Aorta / Obesity / D.M. / Anxiety neurosis

(5) FAMILY HISTORY (Kula Vritta )

Maternal ( Matruja ) / Paternal ( Pitruja ) H.T. / Obesity / D.M. / IHD

(6) MENSTRUAL HISTORY

Rajapravritti : Niyamita / Aniyamita / Alpa / Madhyama / Adhika / Sashula

Ashula / Rajanivritti / Sweta Pradara

Obstetric History : No. of Deliveries / Last Delivery / Normal / Abnormal /

Abortions/Miscarriage / Infertility

(7) TREATMENT HISTORY

(8) PERSONAL HISTORY ( Pratyatma Niyata Vritta )

(a) Dietary ( Ahara ) Samish / Niramisha / Samashana / Adhyashana

Vishamashana / More intake of salt / Fatty diet

(b) Intake of dominant Rasa M / A / L / K / T / Ka

(c) Intake of dominant guna G/L/Sht/Us/Sn/Rks

(d) Sleep ( Nidra ) Sound/Disturbed/Divaswapna/Ratrijagara/

Atinidra

(e) Bowel ( Mala Pravritti ) Regular / Irregular / Constipation / Loose

(f) Micturation ( Mutrapravritti ) Usual / Dysuria / Polyuria / Oliguria

(g) Addiction ( Vyasana) Tea / Coffee / Cigarette / Alcohol / Tobacco

GENERAL EXAMINATON ( Dehabala Pariksha )

( i) Prakrititah ShariraV / P / K / V-P / P-K / V-K / V-P-K

ManasaSatwa / Raja / Tama

( ii) SaratahPravara / Madhyama / Avara

( iii) SamhananatahPravara / Madhyama / Avara

( iv) SatvatahPravara / Madhyama / Avara

( v) SatmyatahPravara / Madhyama / Avara

( vi) Pramanatah Ayama (height ) : Bhara (weight) :

( vii) Vyayama Shakti Pravara / Madhyama / Avara

(viii) Agni Pariksha

Agni Pareeksha / Prakrititah / Vikrititah
Ruci
Abhyavaranashakti
Jaranashakti

NIDANA

Rasavahasrotadusti Nidana Guru, Shita, Atisnigdha, Atimatra –Bhojana,

Atichinta

Raktavahasrotodusti Nidana Vidahi, Snigdha, Ushna, Drava-Annapana, Atapa-

Anala, Sevana, Malinaharashilasya

Medovahasrotodushti Nidana Avyayama, Divaswapna, Madya and Mansa

Bhakshana,Varuni Sevana

Manovahasrotodushti Nidana Malina Aharashila, Viruddha Ahara, Vishama

Cheshta, Kama, Bhaya, Chinta, Krodha, Lobha,

Moha, Irsha,Shoka, Udvega, Harsha, Vishada,

Raja and Tamoguna-Adhikya, Chittodvega.

SYSTEMIC EXAMINATION ( Dosha/Dushya/Srotas/Avayava Pariksha )

SROTASA PARIKSHA

Pareekshya Bhaava / Vata / Pitta / Kapha
Rasavaha Srotas / Rukshata /
Loss of sensation / Angamarda / Krishaangataa / Sweda /Jwara / Vaivarnya /Pandu /
Alpa Kandu / Mukhavirasataa /
Gurutaa / Tandraa Hrillaasa / Aruchi/Annadwesha / Agnimaandya
Hridaya & Dhamani / Palpitation, Tachycardia, Breathlessness on exertion
RaktavahaSrotasa / Raktakshaya/ Amlashishira-prarthana/Sira-shaithilya/Rukshata/
Gulma/ Vatashonita/
Vaivarnya/ Ati-daurbalya/ Kampa/ Swarakshaya/ Charmadala
Pramilaka / Raktapitta/ Upakusha/ Asyapaka/Raktanetrata/ Murccha/Raktamandal/ Putighrana/
Asyagandhita/Mukhapaka/
Visarpa/ Vidradhi/ Rakta-meha/ Pradara/ Pipasa/ Annapanasya Vidaha/ Sweda/ Sharira-daurgandhya / Agni-mandya/
Sira-purnatva/ Agnisada/
Gurugatrata/ Aruchi/
Klama/ Lavanasyata/
Kandu/Kotha/Pidaka
/Kustha
Yakrit & Pliha
Haematolgical
T.L.C.
D.L.C.
T R.B.C.
Hb%
E.S.R. / B.T. / A.T.
N E L M B / N E L M B
R.A Factor
Sr. Uric Acid
Mansavaha Srotasa / Krishata/Ganda-Jangha Sphika-Griva-Ura-Shosha / Adhimansa / Kilak /Galashaluka
/Arbuda/Gandamala/Sphika/
Ganda/Ostha/Bhru/Bahu/
Jangha/UpasthaVriddhi
Snayu & Twaka
Medovaha Srotasa / Ganda-shushkata/Karshyata/
Sandhi-Sfutana-Shunyata/ Glani/ Plihavriddhi/ Hast-Pada Suptata / Snigdhangata/Sphik-Stan-Udar Vriddhi/Sthaulya/
Swedadhikya/ Purvarup of Prameha Balakshaya/Daurbalya/
Hridaya Upalepa
Vrikka,Kati,
Vapavahan
Serum cholesterol
Blood sugar (P.P.)
Asthivaha Srotasa
Majjavaha Srotasa
Shukravaha Srotasa
PranavahaSrotasa / Atisrista/ Kupita/Alpalpa / Atibaddha/ Sashabda Ucchawasa
Nasa/ Kantha/
Ura / Nadi-
Swasa Gati
Annavaha Srotasa / Anannabhilasha/Aruchi/
Avipaka/Chardi
Amashaya
Udakavaha Srotasa / Ostha/Kloma/Jihwa/ Kantha/Talu –Shosha
Atipipasa
Talu &Kloma
Purishavaha Srotasa / Sakashta-Alpalpa-Adhika-Kathina-Atidrava-Sashabda-Sashula (Malaprvritti) Hritparsva pida/Vayoh
SashabdaUrdhvagaman
&Veshtana, Atopa, Adhmana / Adhmana/Atopa/Udara-
Gaurava/Udaravedana
Ostha,Jiva,Talu& Udara
Mutravaha Srotasa / Alpalpa/Sashula / Atisrishta/Atibaddha/
Bahala
Basti,Gavinyaha
Urine Exam.-
-Physical
-Chemical
-Microscopic
-Blood Urea
- S creatinine
Swedavaha Srotasa / Asweda/ Romaharsha
/Parushya/ Romachuti/
Stabdharomata/Twak Sphutana / Atisweda/Paridaha Daurgandhya/ / Kandu
Meda, Romakupa

KAPHAVARGA PARIKSHAA

Vriddhi– Swetata – Twachaa, Mala, Mutra; Shaitya, Sthairya, Gourava,Agnisaada,

Praseka, Swaasa Kaasa, Sandhivishlesha; Avasaada,Tandraa, Aalasya,

Kshaya – Rukshyataa, Trushnaa, Nidraanaasha, Dourvalya, AntardaahaSandhisaithilya,

Hriddrava, Bhrama, Aamaashayetarashlemaasaya Shunyataa, Shirasascha

Shunyata

Prakopa – Kandu, Sthairya, Utsedha, Gourava, Sneha, Supti, Kleda,

Shitataa, Kathinya, Upalepa, Apaaka, Mala-Mutra-Twak- Shwetataa

PITTAVARGA PARIKSHA

Vriddhi : Pita – Vita, Mutra, Netra, Twaka; Kshut, Trut, Daha/Dehe santapa,

Pitavabhasata, Alpanidrata, Shitakamitva, Murccha, Balahani,

Indriyadaurbalya

Kshaya : Mando-analaha, Shaitya, Prabhahani

VAATAVARGA PARIKSHA

Vriddhi : Vakpaarushya (Twakparushya) / Alpavalatwam/ Gadhavarchastwam /

Rukshyataa / Krishataa/Anutsaaha / Adhmaana / Kaarshya

Kshyaya: Mandachestataa / Angasaada / Agnivaisamya/Alpavaaktwam / Saada /

Apraharsha/Alpa Bhasitehitam

Prakopa : Pralaapa / Toda / Anidraa / Angagraha/Vaatavyaadhi Lakshana

SAMPRAPTI VIMARSHA

1)Dosha:-

i) Prithaka (With or without type):

Vata / Pitta / Kapha
PR/ UD/ SM /VN/ AP / PC/ RJ/ BH/ SD/ AL / KL/ AV/ BD/ TR/ SH

ii) Sansarga: Vata-Pitta/Vata-Kapha/Pitta-Kapha

iii) Sannipata : Vata-Pitta- Kapha

2. Dushya :- Dhatu :- Rasa/Rakta/Mansa/Meda/Asthi/Majja/Shukra

Upadhatu :- Stanya/Raja/Kandara/Sira/Dhamani/Twacha/Snau

Mala :- Purisha/Mutra/Sweda/Kapha/Pitta/Khamala/Kesha/Nakha/

Akshisneha/Loma/Shmashru

Sr. No. / Name of Srotasa / Type of Srotodushti / Grade/ Score
B.T. / A.T.
1
2
3
4
5
6 / Rasavah
Raktavah
Medovah
Manovah
Pranavah
Other Srotasas

Adhishthana : Ama/Pakwa...... Vyaktisthana : ………………

Kriyakala : ...... Rogamarga: Ksh / Sha / Marm

Type : Ashu/ Chira / Sant / Apat Bheda : San/Vik/Pra/Ba-Ka/Vid

Upadrava:......

MANAGEMENT

(A)Drug

(B)Dose and Anupan

(C)Pathya / Apathya

(D)Treatment continue up to

PANCHAKARMA (Vasti Karma)

(A)Abhyantara Snehapana with Panchatikta Ghrita (According to Koshtha

1st day ……………... / 2nd day ……………… / 3rd day ………………

4th day………………. / 5th day ……………… / 6th day ……………….

(B)Swedana (Next 3 days)

Pradhana Karma

Drug

Dose

Paschata Karma (Parihar Kal)

After Pariharakala Shamana Yoga is applied for (One month)

Dose and Anupana

Final Result–Aarogya (Cured)/Kinchit Aarogya (Improved)/Anarogya(Unchanged)/

Upadrava (Worsened Response)

Improvement Note in Patient's Language-

Signature of Patient

Signature of Investigator- ------

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