Vous êtes sur la page 1sur 2

FORM F

[See Proviso to Section 4(3), Rule 9(4) and Rule 10(1A)]


FORM FOR MAINTENANCE OF RECORD IN RESPECT OF PREGNANT WOMAN
BY GENETIC CLINIC/ULTRASOUND CLINIC/IMAGING CENTRE .
1

Name and address of the Genetic /Ultrasound


Clinic/Imaging Centre.-

2
3

Registration No.
Patients name and her religion, income& age :

Number of children with sex of each child -

Total: 1

5.

Husbands/Fathers name -

Mr. Mohammd Ashik

6
.

Full address with Tel. No., if any

New Wasti , Ward no-3, House No- 1,


Main Road, Buttibori, Dist- Nagpur Ph9763441678

7
.

Referred by (full name and address of


Doctor(s)/Genetic Counselling Centre

Dr Vinay Tule, Lokmat square, wardha


road, Nagpur

Last menstrual period/weeks of pregnancy

dt : 07/10/12 wk: 17

8
9.

10

11.

12
13.

History of genetic/medical disease in the family


(specify)
Basis of diagnosis:
(a) Clinical
(b) Bio-chemical
(c) Cytogenetic
(d) Other (e.g.radiological, ultrasonography etc.
specify) Indication for pre-natal diagnosis
A. Previous child/children with:
(i Chromosomal disorders
(ii) Metabolic disorders
(iii) Congenital anomaly
(iv Mental retardation
(v) Haemoglobinopathy
(vi) Sex linked disorders
(vii) Single gene disorder
(viii) Any other (specify)
B. Advanced maternal age (35 years)
C. Mother/father/sibling has genetic disease
(specify)
D. Other (specify)

Male: 0

Female : 1

EDD:14/07/13

Not Applicable
Not Applicable
Not Applicable
Ultrasound

NO
NO
NO
NO
NO
NO
NO
NO
YES
NO

--Dr Rajendra Prakashey MMC reg No44552


Non-Invasive
YES
(1)Ultrasound ( specify purposefor which ultrasound is tobe done
During pregnancy) [ List of indications for ultrasonography of pregnant
Women are given in the note below]

Procedures carried out (with name and registration


no. of registered practitioner who performed it

Invasive
(ii)Amniocentesis
(iii) Chorionic Villi aspiration
(iv) Foetal biopsy
(v) Cordocentesis
(vi) Any other (specify)
Any complication of procedure please specify
Laboratory tests recommended1[3] --(i) Chromosomal studies
(ii) Biochemical studies
(iii) Molecular studies
(iv) Preimplantation genetic diagnosis

14.

Shreevardhan Xray and ultrasound


clinic at Shreevardhan commercial
complex. 7,Wardha Road, Nagpur
40
Mrs Naheed Parveen
Hindu, 33yr

Result of
1

YES

CVS- DMD

NO
NO

(a) pre-natal diagnostic procedure (give details)

USG / INVASIVE-CVS:report sent for


exam on
04/02/13
Invasive report normal/ abnormal
Dt
Awaited
}
NORMAL

18.

(b) Ultrasonography
(specify abnormality detected, if any).
Date(s) on which procedures carried out.
Date on which consent obtained. (In case of
invasive)
The
result of pre-natal diagnostic procedure were
conveyed to
Was MTP advised/conducted?

19.

Date on which MTP carried out.-

MTP not done

Date: 04/02/13

Dr Rajendra Prakashey MMC reg No44552

15.
16.
17.

Place : Nagpur

04/02/13
04/02/13
Naheed Parveen on 04/02/13
NO

Name, Signature and Registration number of


the Gynaecologist/radiologist/Director pf the

--------------------------------------------------------------------------------------------------------------------------------------DECLARATION OF PREGNANT WOMAN


I, Mrs Naheed Parveen, declare that by undergoing ultrasonography /image scanning etc.
I do not want to know the sex of my foetus. eh izfrKkiwoZd uewn djrs dh lksuksxzkQh}kjk
eyk xHkZfyax funku djk;ps ukgh- @ eS kiFkiwoZd lwphr djrh gqWz fd]
lksuksxzkQh}kjk fyaxfunku djuk ugh gSA

Signature /thumb of Pregnant woman.


-----------------------------------------------------------------------------------------------------------------------------*strike out whichever is not application or necessary

DECLARATON OF DOCTOR/PERSON CONDUCTING


ULTRASONOGRAPHY/IMAGE SCANNING
I, Rajendra Prakashey (name of the person conducting ultrasonography/image scanning) declare that while
conducting ultrasonography/image scanning on Mrs Naheed Parveen, I have neither detected nor
disclosed the sex of her foetus to any body in any manner.

Dr Rajendra Prakashey.
Name and signature of the person conducting
ultrasonography/image scanning/ Director or owner of
genetic clinic/ ultrasound clinic/imaging centre.

Vous aimerez peut-être aussi