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:

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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
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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
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 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

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 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

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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

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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:

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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 …………..

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