Case Submission

Case Study Submission Form

Instructions: Please fill out and submit the following form. The form has two sections:

1. Personal Contact Information: We'll need this information to get back to you about your submission. This data will not be made available when your case study is placed online.
Note on confidentiality: The last entry box in Section One allows you to give us instructions as to what personal contact information, if any, you would like included with your case study.

2. Written Case Description: Please describe your case, including as much diagnostic, treatment, and outcome information as needed for optimal learning upon review by others. Ten sections have been provided to standardize case studies across practitioners.

Note: Fill in the information you have. If there is an area to fill in information but you do not have it then just leave it blank and continue on through the form.

Please fill out the form below and submit. We will be in contact with you about your submission. Thank you.

Section 1: Health professional information
First name	Last name	Title
Street
City	State		Zip
Office phone	Cell phone
Home phone
Email
The number of cases I have submitted including this is
The Certification I am applying for is: Counselor Consultant
Practitioner instructions and confidentiality requests
Section 2: Patient information
Case identification code (health professional chooses for case)
A. Physical characteristics:
Age Height Weight Sex
Other relevant physical characteristics.
B. Pulse assessment
Overall impression
Vata finger (intensity/qualities)
Pitta finger (intensity/qualities)
Kapha finger (intensity/qualities)
Sub-doshas
Deep pulse
Other relevant pulse findings
C. Brief medical history
Chief complaints/brief history of present illnesses
Relevant past medical history, social history
D.Lifestyle factors (causative factors to be removed)
Diet: suitable and unsuitable items
Behavior and routine: suitable and unsuitable factors
Exercise: balanced, sedentary, over-exercise
Sleep: sufficent/timely, insufficient/untimely, quality
Stress
Environmetal and other relevant factors
*E. Ayurvedic assessment of dosha predominance (Prakriti/Vikriti). through:*
Questionnaires scores if available such as "Prakriti Questionnaire", "Ama Questionnaire" etc
Observation (darshanam)
Palpation (sparshanam)
Interrogation (prashnam)
F. State of digestion
Balanced (sama), irregular (vishama), sharp (tiksna), or dull (manda)
G State of bowel movements
Regular, Irregular/constipated, soft/loose/frequent
H. Presence of Ama
Ama questionnaire/tongue
I. Treatment Plan
Allopathic treatment/medications
Ayurvedic- Dietary recommendations
Ayurvedic- Lifestyle recommendations (modification/removal of causative factors)
Ayurvedic- Mental recommendations/stress-reduction
Ayurvedic- Herbal recommendations
Ayurvedic- other recommendations (e.g., purification procedures, Vedic vibration, aroma therapy, Gandharva music, environmental approaches)
J. Relevant outcomes:
Changes in symptoms, findings, overall health