Ayurveda OP case sheet (blank)
OP No:
Date & time:
Name:
Age / sex:
Phone:
1. Registration
Address
Referred by (R/B)
2. Allergy / adverse drug reaction
None known / Drug / Food / Other
Allergy
Details
3. Special needs
Elderly / Child / Pregnant / Differently abled / Fall risk / Language / Hearing / Vision
Special needs
Details
4. Complaints
Presenting complaints
Aggravating / relieving factors
Pain
Pain site
Pain score (0–10)
K/C/O (known case of)
5. History
H/O presenting complaint
H/O past illness
Investigations (blood, US, X-ray/CT/MRI)
Previous diagnosis
Treatment history
Current medication
Family history
Personal and social history
6. Lifestyle
Appetite
Digestion (acidity, distension)
Bowel
Micturition (day / night)
Sleep
Mental status
Emotions
Periods
Addictions (tea, coffee, tobacco, alcohol, with quantity)
Drinks (milk, other)
Junk food
Reheated food
Drinking water
Head oil
External applications
Bath and frequency
7. Diet and nutrition
Breakfast
Lunch
Dinner
Food allergy / dislikes
Height (cm)
Weight (kg)
Nutritional status
8. Examination
Respiratory rate (/min)
Physical examination
Other observations
Red flags
Referred to
9. Ayurvedic assessment (optional)
Dosha / Dushya
Srotas
10. Diagnosis
D/D (differential)
P/D (provisional)
Final diagnosis
Stage of disease
Stage: Ama / Pachyamana / Nirama / Kshaya / Avarana / Leena / Vishama / Dhatupaka
12. Plan
Plan of care
Plan details
Consent
9. Ayurvedic assessment (optional)
Prakriti
Vikriti (Vata / Pitta / Kapha)
Agni
Koshtha
Ama
Nadi (pulse)
Mutra (urine)
Mala (stool)
Jihva (tongue)
Shabda (voice)
Sparsha (touch)
Drik (eyes)
Akriti (build)
11. Prescription
| No | Medicine | Dose | Anupana | Kala | Frequency | Duration | Total qty |
|---|
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
| | | | | | | |
Pathya (follow)
Apathya (avoid)
12. Plan
Plan of care (Oushadha / Panchakarma / Diet / Investigations / Referral)
Plan details
Consent (N/A / Taken)
Doctor signature
Review visits
Date
Outcome: Relieved / Improved / Better than before / No relief / Worsened
Notes