Clinical Case Sheet

1. Patient’s No :

2. Name :

3. Age :

4. Sex :  Male  Female

5. Address :

6. Religion :  Hindu  Christian  Muslim  Others

7. Marital status :  Married  Widowed  Unmarried

8. Domicile :  Urban  Rural

9. Occupation :  Business  Manual labour  Office staff
 House wife O thers
10. Educational status :  Illiterate  Primary school High School
College
11. Income per Month :  < 500 500-2000  2000-5000  > 5000
12. Socio Economic Status :  Poor  Middle class  Rich
Presenting complaints Duration

Where is the pain?

(ii) How intense is the pain?
(iii) Description of the pain (e.g. burning,
aching, stabbing, shooting, throbbing, etc).

(iv). How did the pain start?

(v) What is the time course of the pain?

(vi) What relieves the pain?

(vii) What aggravates the pain?

(viii) How does your pain affect
(a) Your sleep?
(b) Your physical functions?
(c) Your ability to work?
(d) Your economy?
(e) Your mood?
(f ) your family life?
(g) Your social life?
(h) Your sex life?

(ix) What treatments have you received?

Effects of treatments?
Any adverse effects?

(x) Are you depressed?

(xi) Are you worried about the outcome of
your pain condition and your health?
(xii) Are you involved in a litigation or
compensation

List of M-JOA

Item Grade/Classification Score BT AT

Subjective symptoms
Lumbar and leg pain  No 0
Mild pain or occasional moderate pain 1
Usual moderate pain or occasional severe 2
pain
Frequent or continuous severe pain 3
Numbness  No 0
Occasional 1
Frequent but relief may be on their own 2
Continuous, not alleviated 3
Objective signs
Paravertebral No 0
tenderness 
Mild 1
Moderate 2
Severe 3
Myodynamia  Grade V 3
Grade IV 2
Grade III 1
Item Grade/Classification Score BT AT
Grade 0 to II 0
Straight let raising > 70°, straight leg drive up (-) 0
test 
> 45°, straight leg drive up (+) 1
> 30°, straight leg drive up (+) 2
< 30°, straight leg drive up (+) 3
Radiating pain  No 0
Hip/thigh 1
Shank 2
Foot 3
Activities of daily life
and work
Stoop and lift heavy Normal stoop, lift weight > 3 kg 0
things 
Able to stoop, lift weight ≤ 3 kg 1
Unable to stoop 2
Serious difficulties in bending and lifting 3
Walking Walking ≥ 1 km or 60 min 0
distance/time 
Walking ≥ 500 m or 30 min 1
Walking ≥ 100 m or 10 min 2
Serious difficulties in walking 3
Daily time in bed(h)  < 10 0
10 to 12 1
12 to 16 2
> 16 3
Ability to work  Full-time to do as before 0
Although able to work, occasionally need a 1
break
Although able to work, usually need a break 2
Unable to work 3
 Maine-Seattle Back Questionnaire BT AT
I change position frequently to try and get my back or leg
1
comfortable.
2 Because of my back problem, I use a handrail to get upstairs.
3 I get dressed more slowly than usual because of my back problem
or leg pain(sciatica)
I only stand for short periods of time because of my back problem
4
or leg pain
5 Because of my back problem, I try not to bend or kneel down.
I find it difficult to get out of a chair because of my back problem
6
or leg pain(sciatica)
7 My back or leg is painful almost all the time.
8 I sleep less well because of my back problem.
I stay in bed most of the time because of my back or leg pain
9
(sciatica).
10 Because of my back problem, my sexual activity is decreased.
I keep rubbing or holding areas of my body that hurt or are
11
uncomfortable.
12 Because of my back problem, I am doing less of the daily work
around the house than I would usually do
History of Present illness

History of previous illness

Menstrual History

Treatment History

Family History

Personal history

General Examination

Temperature :

Pulse rate :

Respiratory rate :

BP :

Height :

Weight :
Systemic Examination

Cardio vascular System

S1 S 2

Respiratory System

Breath sounds
Rhonchi crepts

Nervous System
Knee reflex Sensory
Ankle jerk Muscle tone

Gastrointestinal System
Appetite

Bowels – loose stools/ normal/ constipated

Urogenital system

Urine freequency
Colour
Loco motor System
Movements of other joints

Dasavidha Pareeksha

Dooshyam : Dosham V/ P/ K

Dhathu

Malam

Desam : Rogam

Rogi

Balam : Rogam

Rogi

Kalam : Kshanadi

Vyadhyavastha
Analam : Abhyavaharana sakthi

Jarana sakthi

Prakrithi : V  P K
 KP V K  VP S ama
Vayah  ala
:B  Yuva  Vridha

Satwam  ravaram
:P  Madhyam  Avaram

Satmyam :  Eka rasa   rirasa C hatur rasa

Dwi rasa T
 Pancha rasa  Sarva rasa

Aharam :

Investigations BT AT

Diagnosis

Name of the drugs :