Académique Documents
Professionnel Documents
Culture Documents
2
3
Registration No.
Patients name and her religion, income& age :
Total: 1
5.
Husbands/Fathers name -
6
.
7
.
dt : 07/10/12 wk: 17
8
9.
10
11.
12
13.
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
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.
Result of
1
YES
CVS- DMD
NO
NO
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: 04/02/13
15.
16.
17.
Place : Nagpur
04/02/13
04/02/13
Naheed Parveen on 04/02/13
NO
Dr Rajendra Prakashey.
Name and signature of the person conducting
ultrasonography/image scanning/ Director or owner of
genetic clinic/ ultrasound clinic/imaging centre.