Agadtantra Journal 2 by Saket NCISM formatted

MITTAL FOUNDATION TRUST’S

K.G.MITTAL AYURVED COLLEGE

APPROVED BY
NATIONAL COMMISSION FOR INDIAN SYSTEM OF MEDICINES, NEW DELHI
&
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK

SECOND PROFESSIONAL B.A.M.S.
DEPARTMENT OF AGADTANTRA EVAM VIDHIVAIDYAK
( Subject Code :AyUG–AT)

JOURNAL NUMBER - 2
NAME OF THE STUDENT:___________________________________________________________________

INSTITUTIONAL ROLL NO.:___________________________________________________________________________

UNIVERSITY EXAMINATION NO.:_____________________________________________________________

ACADEMIC YEAR:__________________________________________________________________________

MITTAL FOUNDATION TRUST’S

K.G.MITTAL AYURVED COLLEGE
APPROVED BY
NATIONAL COMMISSION FOR INDIAN SYSTEM OF MEDICINES, NEW DELHI
&
MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
DEPARTMENT OF AGADTANTRA EVAM VIDHIVAIDYAK
CERTIFICATE
This is to certify that, Mr./Mrs./Miss___________________________
Enrollment No. (PRN No.)____________________has satisfactorily
completed the course of Practical Agadtantra evam Vidhivaidyak
prescribed by Maharashtra University of Health Sciences, Nashik
as a part of the Second Professional B.A.M.S. Course.
M.U.H.S. Examination Seat No._____________________

Sign of Teacher Sign of H.O.D.

Date of Examination -

Sign of Internal Examiner Sign of External Examiner

INDEX
Sr. No. Date Name of Practical Page No. Sign.
11. Long Case-Related to Any Patient of Poisoning of Any Type
11.1
11.2
11.3
11.4
11.5
11.6
11.7
11.8
11.9
11.10
12.Preparing A Medical Certificate
12.1
12.2

13.Preparing A Report on Injury
13.1
13.2
14. Preparing A Report on Weapon Examination
14.1
14.2

INDEX
Sr. No. Date Name of Practical Page No. Sign.
15.Preparing A Report on Observation of Post Mortem
15.1

15.2

15.3

15.4

15.5

15.6

15.7

15.8

15.9

15.10

16.Determination of Sex on The Basis of Bone Examination
16.1

16.2

INDEX
Sr.no. Date Name of Practical Page No. Sign.
17.Brief Reports of Observation on Every Field Visit and Tour
17.1
17.2
17.3
17.4
17.5
17.6
17.7
18.Brief Report of Participation and Activity Under Student Awareness Program
18.1
18.2
18.3
18.4

TEACHER’S SIGNATURE

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
1
1

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
2
2

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
3
3

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
4
4

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
5
5

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
6
6

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
7

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
8

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
9

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
10

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
11

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
12

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
13

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
14

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
15

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
16

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
17

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
18

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
19

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
20

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
21

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
22

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
23

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
24

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
25

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
26

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
27

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
28

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
29

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
30

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
31

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
32

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
33

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
34

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
35

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
36

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
37

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
38

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
39

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
40

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
41

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
42

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
43

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
44

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
45

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
46

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
47

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
48

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
49

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
50

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
51

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
52

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
53

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
54

Case Record Form : General Format
Date & Time of Discharge :
Present Complaints :
Total Duration :
History of present Illness :
History of past Illness with treatment :
Treatment History of present Illness :
Date of case taking : Case no :
UHID No/ OPD No. IP No/ Dt............................
Name : Age : Sex :
Address with phone no :
Occupation :
Marital status :
Name of nearest Relative with phone no :
Date & Time of Admission :
Income :
Education :
55

Family History:
Personal History:
Fetal History:
Birth History:
Menstrual History: (in the case of woman):
Obstetric History: (in the case of woman):
Diet : (Commonly included ingredients & any notable points on Virudhahara)
Habits : Addictions:
Mode of work:
Sleep/ rest pattern:
General Examination:
Physical Eaxmination:
Temp: Heart Rate: Resp. Rate: B.P.
Body Weight: Koshta: Akruthi:
Systemic Eaxmination:
Gastro Intestinal System: Cardio Vascular System:
Respiratory System: Skin & Appendages:
Others:
56

Dashavidha Pareeksha:
Routine & Specific Laboratory Investigations:
Blood:
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analysis of the Case:
Vishabheda: (Sthavara / Jangama / Kritrima / Doosheevisha / Garavisha / Vishopama)
Sthavara vishabheda:
Dushyam: Dosham: Desam: Deham: Bhumi:
Dhatu: Balam: Rogi: Rogam:
Malam:
Kalam: Kanadi: Vyadhivridhi:
Chikitsa: Vyadhyavasha:
Anala: Prakruthi: Vaya: Satva:
Satmya: Ahara: Vihara
Ahara: Jaranasakthi: Abhyavaharanasakthi:
Ashtasthana Pareeksha: (Observations. Doshas involved)
Nadi: Jihwa: Malam: Mutram:
Drik: Sabdam: Sparsam: Akruthi:
Signs & Symptoms:
Saamanya lakshana:
Vega Lakshana:
Anubandha Upadrava:
57

Jangama vishabheda:
1. Characters of snake:
2. Place of bite (Damsa sthaana)
3. Time of bite (Damsa samaya):
4. Time elapsed between bite & Admission:
5. Part of body affected:
6. Nature of bite (Damsasya bhaava):
7. Signs & Symptoms (Damsa lakshanaani):
8. Samanya Lakshana:
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrima vishabheda:
Signs& Symptoms: Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha:
Lakshanaani:
Doosheevishajanya roga:
Anubandha upadrava:
Indriya pareeksha:
Vishopama Samprapti:
Virudhahara:
Type of virudhara :
Factors involved:
Samanya Lakshana:
58

Ama :
Doshadhikya:
Samanya Lakshana:
Dosha & Vikruta lakshanaani:
Dooshya & Vikruta lakshanaani:
Srotas & Dushti lakshanaani:
Vyaadhyadhishtaanam:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actual:
Treatment:
Chaturvimshati upakrama:
Saamanya chikitsa:
Sodhana chikitsa:
Samana chikitsa:
Details of Treatment
ObservationsDate Medicines/Procedure Dose/ Time Duration
59

Pathya:
Ahara:
Vihara:
Apathya:
Ahara:
Vihara:
Chikitsaphalam:
Advice given at the time of discharge:
MedicineSr.No Dose Duration Anupana
Signature of Student Signature of Teacher
60

I hereby certify that the deceased Shri/Smt/Kum…....................................................son of/wife of/daughter
of…………………………resident of......................................was under my treatment
from………......to…………..… and he/she died on…..………........at..............................am/pm.
Signature of Student Signature of Teacher
MEDICAL CERTIFICATE OF CAUSE OF DEATH
Name of institution Hospital in-Patients
(Not to be used for still births)
Admission no.
Name of deceasedGenderMarital statusDate of birthDate and time of death
Age at death Age in
completed
in years
If less than 1
year age
in month
If less than one
month
age in days
If less than 1 day , age
in hrs
Immediate cause
(Disease or condition
directly leading to
death)
Antecedent Causes
(Morbid conditions, If
any, giving rise to the
above cause, stating
the underlying
condition last.)
Contributory
Cause Other
Significant Conditions
contributing to the
death but not related
to the disease
condition causing it.
Approximate Interval
between
onset and death
Address
Cause of Death
If deceased was a female, was pregnancy the death associated with?- YES/NO
If yes, was there a delivery?- Yes/ No
Signature of Student Signature of Teacher
(To be detached and handed over to the relative of the deceased)
Certified that Shri/Smt/Km….................................S/W/D of Shri...........................................................R/O
.................................................................................. was under treatment
from………….......and he/she expired on........... at..............am/pm
61

I hereby certify that the deceased Shri/Smt/Kum…....................................................son of/wife of/daughter
of…………………………resident of......................................was under my treatment
from………......to…………..… and he/she died on…..………........at..............................am/pm.
Signature of Student Signature of Teacher
MEDICAL CERTIFICATE OF CAUSE OF DEATH
Name of institution Hospital in-Patients
(Not to be used for still births)
Admission no.
Name of deceasedGenderMarital statusDate of birthDate and time of death
Age at death Age in
completed
in years
If less than 1
year age
in month
If less than one
month
age in days
If less than 1 day , age
in hrs
Immediate cause
(Disease or condition
directly leading to
death)
Antecedent Causes
(Morbid conditions, If
any, giving rise to the
above cause, stating
the underlying
condition last.)
Contributory
Cause Other
Significant Conditions
contributing to the
death but not related
to the disease
condition causing it.
Approximate Interval
between
onset and death
Address
Cause of Death
If deceased was a female, was pregnancy the death associated with?- YES/NO
If yes, was there a delivery?- Yes/ No
Signature of Student Signature of Teacher
(To be detached and handed over to the relative of the deceased)
Certified that Shri/Smt/Km….................................S/W/D of Shri...........................................................R/O
.................................................................................. was under treatment
from………….......and he/she expired on........... at..............am/pm
62

MEDICAL FITNESS CERTIFICATE
This is to certify that I have carefully examined
Mr./Mrs………………………....................…S/o,D/o......................................
........aged……...…………Village……….......………District………………
…......………...….Stat.......……....………..Pin Code……………….........
He / she is in good mental and physical health and is free from any physical
defects such as deafness, color blindness and any chronic or contagious
diseases.
This certificate is being issued to him/her for the purpose
of……………….............….
Signature of the
Patient / Person (In Identification)
............................................................
Signature of Student Signature of Teacher
Date.......................
63

MEDICAL FITNESS CERTIFICATE
This is to certify that I have carefully examined
Mr./Mrs………………………....................…S/o,D/o......................................
........aged……...…………Village……….......………District………………
…......………...….Stat.......……....………..Pin Code……………….........
He / she is in good mental and physical health and is free from any physical
defects such as deafness, color blindness and any chronic or contagious
diseases.
This certificate is being issued to him/her for the purpose
of……………….............….
Signature of the
Patient / Person (In Identification)
............................................................
Signature of Student Signature of Teacher
Date.......................
64

MEDICAL CERTIFICATE OF ILLNESS
I, Dr........................................................after careful personal examination of
case herby certify that.............................................................................whoes
signature is given below, is suffering
from...............................................................that I consider that a period of
absence from duty for.....................................................................with effect
from..................to………………..is absolutely for restoration of his/her
health.
Place.......................
Date........................
Signature of Student Signature of Teacher
Signature of the
Patient / Person (In Identification)
............................................................
65

MEDICAL CERTIFICATE OF ILLNESS
I, Dr........................................................after careful personal examination of
case herby certify that.............................................................................whoes
signature is given below, is suffering
from...............................................................that I consider that a period of
absence from duty for.....................................................................with effect
from..................to………………..is absolutely for restoration of his/her
health.
Place.......................
Date........................
Signature of Student Signature of Teacher
Signature of the
Patient / Person (In Identification)
............................................................
66

CERTIFICATE OF MEDICAL FITNESS

Signature of Applicant______________________________________

I, Dr.________________________________do hereby certify that I
have carefully examined Mr./Mrs_______________________
of _______________the____________________ ___who was suffering
from__________________________and Whose signature is given above,
and find that he/ she has recovered from his/ her illness and is now fit to
resume duties. I also certify that before arriving at this decision I have
examined original medical certificates and statements of the case on which
leave was granted or extending, and have taken these in consideration in
arriving at my decision.

Place...................
Date........................

Signature of student Signature of Teacher

67

CERTIFICATE OF MEDICAL FITNESS

Signature of Applicant______________________________________

I, Dr.________________________________do hereby certify that I
have carefully examined Mr./Mrs_______________________
of _______________the____________________ ___who was suffering
from__________________________and Whose signature is given above,
and find that he/ she has recovered from his/ her illness and is now fit to
resume duties. I also certify that before arriving at this decision I have
examined original medical certificates and statements of the case on which
leave was granted or extending, and have taken these in consideration in
arriving at my decision.

Place...................
Date........................

Signature of student Signature of Teacher

68

INJURY REPORT
Officer................................................................................................ Ref. Your
letter No................................................................................................... dated....................................
I have the honour to forward herewith theresult of my examination of...............................................
............................................... Son/daughter/Wife............................................................ resident of
....................................................................................... Tahasil.....................................P.S................
......................................................... District ...............................................................
Sr.
No.
To,
The investigating Police
Nature
of
Injury
Size of
Injury
Situation
on body
Simple
or
Grievous
Kind of
Weapon
Age of
Injury
Remark
Consent for Examination :
Question asked: Are you ready to get examined by me?
Reply given: Yes / No
Signature or thumb impression of the person
Identification Marks 1)
2)
Signature of Student Signature of Teacher
7
69

INJURY REPORT
Officer................................................................................................ Ref. Your
letter No................................................................................................... dated....................................
I have the honour to forward herewith theresult of my examination of...............................................
............................................... Son/daughter/Wife............................................................ resident of
....................................................................................... Tahasil.....................................P.S................
......................................................... District ...............................................................
Sr.
No.
To,
The investigating Police
Nature
of
Injury
Size of
Injury
Situation
on body
Simple
or
Grievous
Kind of
Weapon
Age of
Injury
Remark
Consent for Examination :
Question asked: Are you ready to get examined by me?
Reply given: Yes / No
Signature or thumb impression of the person
Identification Marks 1)
2)
Signature of Student Signature of Teacher
7
70

Report of examination of Weapon of offence
Officer................................................................................................ Ref. Your
letter No................................................................................................... dated....................................
To,
The investigating Police
Signature of Student Signature of Teacher
Sir, with reference to the above letter, I hereby submit the report about the weapon -
Name of the Weapon -
Type of the Weapon -
Description
Blade -
Length -
Breadth -
Margins -
Points -
Thickness or Circumference -
Handle -
Length -
Breadth or Circumference -
Texture -
Joint -
Injuries Possible -
Injuries Impossible Stains (if any) - Prints (if any) -
Foreign Body (if any) -
Identification Mark (if any) -
The weapon is packed sealed and handed over to the police constable .............................................
.............................................. Buccal No.......................... Police Station ..........................................
8
71

Report of examination of Weapon of offence
Officer................................................................................................ Ref. Your
letter No................................................................................................... dated....................................
To,
The investigating Police
Signature of Student Signature of Teacher
Sir, with reference to the above letter, I hereby submit the report about the weapon -
Name of the Weapon -
Type of the Weapon -
Description
Blade -
Length -
Breadth -
Margins -
Points -
Thickness or Circumference -
Handle -
Length -
Breadth or Circumference -
Texture -
Joint -
Injuries Possible -
Injuries Impossible Stains (if any) - Prints (if any) -
Foreign Body (if any) -
Identification Mark (if any) -
The weapon is packed sealed and handed over to the police constable .............................................
.............................................. Buccal No.......................... Police Station ..........................................
8
72

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
73

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
74

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
75

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
76

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
77

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
78

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
79

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
80

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
81

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
82

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
83

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
84

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
85

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
86

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
87

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
88

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
89

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
90

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
91

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
92

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
93

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
94

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
95

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
96

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
97

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
98

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
99

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
100

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
101

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
102

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
103

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
104

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
105

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
106

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
107

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
108

Agadtantra evam Vidhi Vaidyak
Memorandum of a post mortem examination held at
Dispensary / Hospital on the dead body of village/city
Taluka District By
I) GENERAL PARTICULARS
1) a) By whom was the corpse sent?
b) Name of place from which sent?
c) Distance of place from which sent?
2) By whom was the corpse brought?
3) By whom identified?
4) The date, hour and minute of its receipt
a) The date, hour and minute of beginning
post-mortem examination.
b) The date, hour and minute of ending
post-mortem examination
5) Substance of accompanying Report from Police
Officer of Magistrate together with the date of
death, if known supposed cause of death or
reason for examination.
6) If not examined at Dispensary or Hospital
a) Name of place where examined.
b) Distance from Dispensary or Hospital
c) Reason why the body was not sent to
the dispensary or Hospital.
II) EXTERNAL EXAMINATION
7) Sex, apparent age, race of cast
description of clothes and of ornaments
on the body.
8) Condition of the clothes.
Whether wet with water, stained with blood or
soiled with vomit or focal matter
9
109

9) Special marks on the skin, such as scars,
tattoos etc. any malformations. Peculiarities or
other marks of identification. State of theteeth
in newly born infants, the length and (if
possible), the weight of the body to be
recorded together with the state of the hair,
nails and umbilical cord, its length whether
placenta is attached or not, if present,
its size and condition.
10) Condition of body
Whether well -nourished, thin or
emaciated warm or cold
11) Rigor Mortis
Well marked, Slight or absent
Whether present in the whole body or part only
12) Extent, and signs of decomposition
Presence of post-mortem lividity at buttocks.
Joints, back and thighs or any other part.
Whether bullae present and the nature of their
contained fluid condition.
13) Features
Whether natural swollen.
(State of eye, position of tongue, nature of fluidof
any) oozing from mouth, nostrils or ears.
14) Condition of skin
Marks of blood etc. (In suspected Drowning) the
presence or absence of Cutes anserine
to be noted.)
15) Injuries to external genitals, indication of purging
16) 1Position of limbs
Especially of arms and of fingers in suspected
Drowning, the presence or absence of sand
Earth within the nails or the skin of hand and feet
10
110

17) Surface wounds and injuries -
Their nature, position, dimension,
(measured) and directions to be
accurately stated - their Probable age
and causes to benoted. If bruisesto be
present, what is the condition of the
subourtaneous tissures ? (N. B. when
injuries are numerous and cannot be
mentioned within the space available,
they should be mentioned on a separate
paper which should be signed.)
18) Other injuries discovered by
external examination or palpation
as fractures, etc.
Can you say definitely that the
injuriesshown against Sr. No.
17 and 18 are ante-mortem injuries?
III) INTERNAL EXAMINATION
19) Head
a) Injuries under the scalp, their nature.
b) Skull - Vault and base describe
fractures, their sizes, dimensions,
directions etc.
c) Brain - The appearance of its
coverings, Size, weight and general
condition of theorgan itself and any
abnormally found in its examination
to be carefully notes with weight.
20) Thorax
a) Walls, ribs, cartilages
b) Pleura
c) Larynx, Trachea and Bronchi
d) Right Lung
e) Left Lung
f) Pericardium
g) Heart with weight
h) Large vessels
i) Additional remarks
11
111

21) Abdomen
a) Walls
b) Peritoneum
c) Cavity
d) Bucal Cavity, teeth, tongue and pharynx
e) Esophagus
f) Stomach and its contents
g) Small intestine and its contents
h) Liver (with weight) and gall bladder
i) Pancreas and suprarenals
j) Spleen with weight
k) Kidneys with weight
l) Bladder
m) Organs or generation
22) Abdomen remarks with where
possible, medical officer's deduction
from the state of the contents of the
stomach as to time ofdeath and last
meal.
23) State which viscera (if any) have
been retained for chemical
examination and also quote the
numbers on the bottles containingthe
same.
24) Opinion as to the cause / probable
causeof death.
Date
Signature of Student Signature of Teacher
12
112

Report of sex determination based on pelvis
.......................................................................................................................................
Ref. - Your letter No............................................................ dated....................................
Sr.
No.
To,
The investigating Police Officer
Sir, with reference to the above letter, I hereby submit the report of examination
of bone/s submitted by you –
Feature Description
Opinion – Sex of the person is – Male / Female
Date – Time - Place –
13
113

Report of sex determination based on pelvis / Diagram piture
Signature of Student Signature of Teacher
14
114

Report of sex determination based on Femur
.......................................................................................................................................
Ref. - Your letter No............................................................ dated....................................
Sr.
No.
To,
The investigating Police Officer
Sir, with reference to the above letter, I hereby submit the report of examination
of bone/s submitted by you –
Feature Description
Opinion – Sex of the person is – Male / Female
Date – Time - Place –
15
115

Report of sex determination based on Femur / Diagram piture
Signature of Student Signature of Teacher
16
116

Report of Field Visit
Place –
Date –
Observations –
Signature of Student Signature of Teacher
Visit To
117

Report of Field Visit
Place –
Date –
Observations –
Signature of Student Signature of Teacher
Visit To
118

Report of Field Visit
Place –
Date –
Observations –
Signature of Student Signature of Teacher
Visit To
119

Report of Field Visit
Place –
Date –
Observations –
Signature of Student Signature of Teacher
Visit To
120

Report of Field Visit
Place –
Date –
Observations –
Signature of Student Signature of Teacher
Visit To
121

Report of Field Visit
Place –
Date –
Observations –
Signature of Student Signature of Teacher
Visit To
122

REPORT OF VISIT TO COURT
1. Date of Visit:
2. Time of Visit:
3. Type of Court:
4. Address:
5. Observed case No.:
6. Name and designation of witness observed:
7. Type of Examination observed: Main/Cross/ Re-examination/All
8. Observations:
Signature of Student Signature of Teacher
123

REPORT OF PARTICIPATION AND ACTIVITY UNDER
STUDENT AWARNESS PROGRAM
Place:
Date:
Rally/Activity Name:
Organizer name (Organization/Institute)
Details Rally/Activity:
Signature of Student Signature of Teacher
PROGRAM NAME :
124

REPORT OF PARTICIPATION AND ACTIVITY UNDER
STUDENT AWARNESS PROGRAM
Place:
Date:
Rally/Activity Name:
Organizer name (Organization/Institute)
Details Rally/Activity:
Signature of Student Signature of Teacher
PROGRAM NAME :
125

REPORT OF PARTICIPATION AND ACTIVITY UNDER
STUDENT AWARNESS PROGRAM
Place:
Date:
Rally/Activity Name:
Organizer name (Organization/Institute)
Details Rally/Activity:
Signature of Student Signature of Teacher
PROGRAM NAME :
126

REPORT OF PARTICIPATION AND ACTIVITY UNDER
STUDENT AWARNESS PROGRAM
Place:
Date:
Rally/Activity Name:
Organizer name (Organization/Institute)
Details Rally/Activity:
Signature of Student Signature of Teacher
PROGRAM NAME :
127

Signature of Student
Declaration of Geneva
"I solemnly pledge to dedicate my life to the service of humanity.
The health and well-being of my patient will be my first consideration.
I will respect the autonomy and dignity of my patient.
I will maintain the utmost respect for human life.
I will not permit considerations of age, disease or disability, creed, ethnic
origin, gender, nationality, political affiliation, race, sexual orientation,
social standing or any other factor to intervene between my duty and
my patient.
I will respect the secrets that are confided in me, even after the patient
has died.
I will practice my profession with conscience and dignity and in
accordance with good medical practice.
I will foster the honour and noble traditions of the medical profession.
I will give to my teachers, colleagues, and students the respect and gratitude
that is their due.
I will share my medical knowledge for the benefit of the patient and the
advancement of healthcare.
I will attend to my own health well-being, and abilities in order to provide
care of the highest standard.
I make these promises solemnly, freely, and upon my honour."
The Declaration of Geneva emphasizes the physician's commitment to
their patients' well-being, the importance of respecting patient
autonomy, and the need to uphold the highest ethical standards in
medical practice. It serves as a guiding principle for physicians
worldwide and reaffirms their dedication to the ethical practice of
medicine.
The Declaration of Geneva is a statement that was adopted by the
World Medical Association (WMA) in 1948 and adopted by MCI and
MCIM, Mumbai, as a modern-day revision of the Hippocratic Oath.
It serves as an ethical guide for physicians worldwide. The text of the
Declaration of Geneva is as follows:
128

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