Clinical Case Proforma For M.S. Research Work: Affiliated by Utkal University, Vanivihar, Bhubaneswar, Odisha

RESEARCH PROFORMA
CLINICAL CASE PROFORMA FOR M.S. RESEARCH WORK

POST GRADUATE DEPARTMENT OF PRASUTI TANTRA & STREE ROGA
G.A.M., PURI
Affiliated By Utkal University, Vanivihar, Bhubaneswar, Odisha

TITLE OF THE STUDY :- ―A CLINICAL STUDY ON RAKTAPRADARA AND ITS
MANAGEMENT WITH DHATRYADI CHURNA
Guide Research Scholar

Prof. Dr. Aruna Mohanty Dr.Rohit Kumar Chhatria
Register No. Date of Register

OPD No. Date of Admission
IPD No. Date of Discharge
Bed No.
Name of the patient
Husband’s name
Occupation of husband
Address
Age
Marital status Married / Unmarried
Religion Hindu / Muslim / Christian / other
Economical Status Poor / Middle class / Rich
Educational status Illiterate/Primary School/High School/College
Occupation
Group A B
1. Chief complain with duration :
2. History of present illness:
3. History of past illness:
“A CLINICAL STUDY ON RAKTAPRADARA AND ITS MANAGEMENT WITH DHATRYADI CHURNA” Page 138
RESEARCH PROFORMA
a. Medical History – STD / DM / Hypertension / Other

b. Surgical history – D & C / any cervical trauma / any other
c. Drug history – antispasmodic / analgesic / hormonal / any other
4. Family history: T.B / Hypertension / Diabetes / STD / HIV/ Others
5. Menstrual history:
Menarche
Regularity Regular/Irregular
Duration of flow
Interval
Amount of flow Moderate / Excessive
Intensity of bleeding Total no. of pads used in one cycle

Odour Foul / Normal
Colour of menstrual blood Frank Blood / Dark / Black
Nature of flow With Clot / Without Clot
L.M.P
Others
6. Obstetrical history:
Married life
Gravid
Para
Live birth with age Male Female
Abortion Spontaneous Induced
Mode of delivery FTNVD / Forceps / Ventouse / C.S
Last delivery
7. Contraceptive history:
Contraceptive education Yes / No

Method of contraception
Temporary OCP / IUCD / Condom / Others
Permanent
8. Personal history:
Birth place Aanoop / Jangal/ Sadharan

Residence Aanoop / Jangal/ Sadharan
RESEARCH PROFORMA
Diet Veg. / Non-veg. / spicy / Normal

Appetite Poor/ Good
Koshtha Kroora / Madhya / Mridu
Addiction Tea / coffee I Tobacco/ Alcohol Nothing / Any other
Bowel Regular / Irregular / Constipated / Loose motion
Urination Usual / Burning / Dysuria / Others
Thirst Normal / Increased / Decreased
Personal hygiene Proper/poor
Sleep Normal /Disturbed/Good
Sexual life Satisfactory/ Non satisfactory
9. Astavidha Pareeksha:
Nadi V / P / K / VP / VK / PK / T Sama /
Vishama
Mala Sama / Nirama
Mutra Prakruta / Vikruta Prakruta / Vikruta
Jihva Nirama( Uncoated)/Amayukta ( coated )
Shabda Vishesha / Avishesha
Sparsha Ushna / Sheeta / Samashitoshana
Drika Prakrita / Vaikruta
Akriti Sthula / Nladhyama / Krisha
1. Physical Examination-
A) General Examination-
 Built - Average / Thin / Obese
 N u t r i t i o n a l S t a t u s — G o o d / A ve r a ge / P oo r
 Anaemic — Absent / Mild / Moderate / Severe
 Oedema - Absent/ Present
 P ul se R at e —
 Bl ood P ressure -
 Temperature-
 Weight
RESEARCH PROFORMA
 Respiration Rate-
 Psychological Status — Stress / Anxiety / Depression
 Breast
 Skin —
 Oral cavity-
 Any other—
B) Gynecological Examination-1.
Abdomen -
 Inspection -
 Palpation –
 Auscul t at i on
 2. Pelvic Examination
i. External Genitalia: Appearance Discharge
Scars ` Perineum
ii. Per Spaculum : _

1. Vulva — Normal / Warts / Red / White patches / Excoriated
2. Vaginal Mucosa — Normal / Red / Inﬂamed / Ulcerated
3. Vaginal wall condition —

Colour - Pink / Red / Pale
Discharge - Yes / No
Any growth - Yes / No
4. Discharge-
 Amount — Mild / Moderate / Excessive
 Colour - White / Curdywhite / Greenish Yellow / Yellow
 Odour - Present / Absent
 Consistency — Normal / Watery / Mucoid / Prulent
5. Cervix —
 Ext. Os. — Parous / Nulliparous / Pinhole
 Erosion — Present /Absent.
 Nabothian cyst — Present /Absent
RESEARCH PROFORMA
 Hypertrophied — Yes / No
 Size - Elongated / Normal
 Abnormal Growth - Present /Absent
6. Fornices — Clear / Any pathology
iii. Per Vaginal:

1. Uterus-
.
 Position—AV/ AF/ RV/ RF/ Deviated
 Size - Normal / Bulky/ Small
 Mobillity — Mobile/ Restricted mobility / Fixed
2. Cervix —
 Consistency — Firm / Soft / Granular

 Movement — Painful / Painless
3. Fornices
 Anterior — Normal / Tender / Abnormal growth

 Posterior - Normal / Tender / Abnormal growth
 Lateral-
Rt. - Normal / Tender / Abnormal growth
Lt.- Normal / Tender / Abnormal growth
2. Assessment Parameters-
a) Amount of blood loss
Amount of blood loss score Before Follow Follow of After

with no. of pads treatment of treatment
Normal (2 pads) 0
Moderate (2 to 4 pads) 1
Heavy (4 to 7 pads) 2
Excessive 3
(more than 7 pads)
b) Duration of blood flow
Duration score Before Follow of Follow of After

treatment treatment
Less than 5 days 0
6-7 days 1
RESEARCH PROFORMA
8-9 days 2
More than 9 days 3

c) Consistency of bleeding
Consistency of score Before Follow of Follow of After

bleeding treatment treatment
Watery 0
Watery +clot 1
Watery + heavy 2
clot
Heavy clot 3
d) Body ache
Grading of body Score Before Follow of Follow of After

ache treatment treatment
No body ache 0
except hard work
After moderate 1
work for a
certain time
After light work 2
for a certain time
After routine 3
activities for a
certain time
e) Pallor
Pallor Score Before Follow of Follow of After

treatment treatment
No pallor 0
Pallor of conjunctiva 1
Pallor of conjunctiva, 2
nail,tongue
Pallor of conjunctiva, 3
nail, tongue, skin,palm
and sole
Lab investigation
Blood Investigation
RESEARCH PROFORMA
Before treatment After treatment

1 Hb%
2 TLC
3 ESR
4 BT,CT
5 URINE (Routine and microscopic)
6 Other
USG :
Treatment :
Drug Dose Anupana Duration
Group A Dhatryadi churna 3 gram BD Water 3 cycles
Group B Desogesterol-0.15mg + 1 tab. Daily for 21 Water 3 cycles

Ethinyl oestradiol-20µg days(5th to 25th )
 Pathya ahara/ Vihara
 Apathy ahara / Vihara
 The patient has completed the study according to Protocol- Yes/No

 Date of completion of Study-
 Reason for withdrawl/ Dropout
 Adverse effect-
 Unassociated illness
Signature:
Scholar: Guide:
RESEARCH PROFORMA
PATIENT CONSENT FORM FOR CLINICAL TRIAL

TITLE OF THE STUDY :- ―A CLINICAL STUDY ON RAKTAPRADARA AND ITS
MANAGEMENT WITH DHATRYADI CHURNA‖
I………………………… Daughter/ wife of ……………………….. …exercise my free

favor of choice here by give my consent to be treated with Prasuti tantra & Stree roga
subject of clinical trial. I have been informed to my satisfaction ,by the attending
physician the purpose of clinical trial and the nature of drug treatment and follow-up
including laboratory investigations to monitor and safe guard my body function. My
name and others details will be kept confidential. I am also aware of my right to withdraw
from the trial at any time during the course of trial without having to give the reasons of
doing so.
Signature of Researcher Signature / Thumb impression

of the patient
Date………………
Place …………..

Clinical Case Proforma For M.S. Research Work: Affiliated by Utkal University, Vanivihar, Bhubaneswar, Odisha

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Clinical Case Proforma For M.S. Research Work: Affiliated by Utkal University, Vanivihar, Bhubaneswar, Odisha

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RESEARCH PROFORMA

CLINICAL CASE PROFORMA FOR M.S. RESEARCH WORK

Affiliated By Utkal University, Vanivihar, Bhubaneswar, Odisha

Guide Research Scholar

Register No. Date of Register

1. Chief complain with duration :

2. History of present illness:

3. History of past illness:

a. Medical History – STD / DM / Hypertension / Other

4. Family history: T.B / Hypertension / Diabetes / STD / HIV/ Others

Intensity of bleeding Total no. of pads used in one cycle

Contraceptive education Yes / No

Birth place Aanoop / Jangal/ Sadharan

Diet Veg. / Non-veg. / spicy / Normal

 Built - Average / Thin / Obese

 Anaemic — Absent / Mild / Moderate / Severe

 Oedema - Absent/ Present

 Psychological Status — Stress / Anxiety / Depression

i. External Genitalia: Appearance Discharge

ii. Per Spaculum : _

2. Vaginal Mucosa — Normal / Red / Inﬂamed / Ulcerated

3. Vaginal wall condition —

6. Fornices — Clear / Any pathology

iii. Per Vaginal:

 Consistency — Firm / Soft / Granular

 Anterior — Normal / Tender / Abnormal growth

Amount of blood loss score Before Follow Follow of After

b) Duration of blood flow

Duration score Before Follow of Follow of After

More than 9 days 3

Consistency of score Before Follow of Follow of After

Grading of body Score Before Follow of Follow of After

Pallor Score Before Follow of Follow of After

Before treatment After treatment

Group B Desogesterol-0.15mg + 1 tab. Daily for 21 Water 3 cycles

 Pathya ahara/ Vihara

 Apathy ahara / Vihara

 The patient has completed the study according to Protocol- Yes/No

PATIENT CONSENT FORM FOR CLINICAL TRIAL

I………………………… Daughter/ wife of ……………………….. …exercise my free

Signature of Researcher Signature / Thumb impression

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