APPENDIX VAIDYA RATNAM AYURVEDA COLLEGE HOSPITAL. Proforma. Address. Married/unmarried If married Husband s name. Age Education Occupation
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1 APPENDIX VAIDYA RATNAM AYURVEDA COLLEGE HOSPITAL Proforma Name OP NO. Age IP No. Education DOA Occupation DOD Address Nearest Relative Body built Married/unmarried If married Husband s name Parity Rural Urban Income Age Education Occupation Slum Total family income/month Chief complains with duration Menstrual history Nature of periods Menarche Regular irregular LMP Duration Amount of blood loss moderate excessive Duration in days Interval
2 Clots Colour Mild Moderate Severe Bright red Dark red Odour Pain Degree Site Onset pre, pan, post menstrual Mild moderate severe Low back lower abdomen thigh Inter menstrual bleeding Weakness Vertigo Nausea Vomiting Body pain Breast discomfort Constipation Headache Backache Burning sensation Other complaints History of present illness UTI Recurrent TB Severe anaemia, diabetic mellitus typhoid jaundice, Chronic asthma, rheumatic fever Rheumatic arthritis any other Personal history Personal habits Tobacco alcohol drugs Exposure to outdoor air pollution Mobile (Motor vehicle) Stationary (Factory) Other sources
3 Exposure to indoor air pollution Gas cooking stove Wood stove Construction material Allergens Dust Fungal spore and bacteria Industrial exposure Aliphatic hydrocarbon Petroleum products Aromatic hydrocarbon Plastic rubber polymer Metals Agricultural hazards Insecticides Herbicides Fungicides Rodenticides Furmigants Exposure to natural toxins Myocotoxins Aspergillus Phytotoxins Flour adulterations Black pepper Solanacea plant Animal toxins Snake Bees Radiation injury Addictions Coffee tea Hormone fed animal products agricultural pesticides Food contaminants Broiled meat sweeteners Preservatives, food colour
4 Family history Cervical carcinoma cervical polyp Fibroid, leucorrhoea Breast carcinoma TB DM Dysmenorrhea mother sister grandmother DUB Mother Sister Grandmother Diet Veg Non Veg Fried food sweet bitter salt Sour hot cold cereals fruits low protein nutritive History of Gynaecological diseases PID Pelvic abscess Fibroid Ovarian Cyst DUB Syphyllis Gonorrhoea Endometriosis Prolapse Cervical Erosion History of surgical interventions Laporotomy MTP I, II, III, >IV D&C I, II, >II Radiation Laporotomy Ovarian cystotomy Oophorectomy Myomectomy Hysterotomy History of Hormone Therapy Hygiene Poor Good Bad Obstetric History No., year and date Pregnancy events Labour events Method of delivery Contraceptive history Sterilization done not done Temporary Puerperium Baby weight asphyxia, breast feeding
5 Temporary Permanent Oral Pill Permanent IUCD Date Duration Date of removal Side effects Name Surgical procedure General examinations Built lean moderate obese Hot BP respiratory rate Pulse rate Physical examinations Head Hair forehead eye conjunctiva pallor anaemia, Nose presence of polyp Curvature of alae Gum Tongue Pharynx Thyroid Pulsation Lymphanode Upper limb Reflexes Wasting Functions Thorax Breast Development Swelling Heart Auscultation Purcussion Palpation lungs Abdomen Contour Swelling Pigmentation Palpation Purcussion Liver
6 Spleen Any abnormal mass Inguinal lymphnode Hypochondrium R. Lumbar R. iliac Epigastrium Umbilicur Hypogastrium Pelvis Presence of pelvic hair normal scanty thick Ex. Genitalia Urethra Vulva Labia Hymen Cystocele Rectoule Prolapse P/s vagina Discharge Present Absent Abnormal growth Present absent Cervix Position middle Ant Post Consistency Hard Soft atrophied Size Hypertrophied normal atrophied Cervicitis Erosion Abnormal growth P/V Uterus Size NS/PS Smaller Smaller than normal bigger Position AV/RV Mobility Freely movable restricted fixed Consistency Normal hard soft Appendages Tubes Tenderness Ovaries Palpable Hypochondrium Lt. Lumbar Iliac
7 If Palpable Size Shape Mobility Consistency Microscopic examination Blood TC DC ESR Blood sugar Other ABO Rh VDRL Other Urine M RBC Sugar Albumin Puss Cells Stood Xray USG Others Diagnosis Treatment Type of medicine given Followup Interval Duration Site of pain Amount Clots Presence of associated symptoms After 3 months
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