[See Rule 9(3)]
FORM FOR MAINTENANCE OF RECORDS BY GENETIC LABORATORY
1. Name and address of Genetic Laboratory
2. Registration No
3. Patient’s name
5. Husband’s/Father’s name
6. Full address with Tel. No., if any
7. Referred by/sample sent by (full name and address of Genetic Clinic) (Referral note to be preserved carefully with case papers)
8. Type of sample: Maternal blood/Chorionic villus sample/amniotic fluid/Foetal blood or other foetal tissue (specify)
9. Specify indication for pre-natal diagnosis
A. Previous child/children with
(i) Chromosomal disorders
(ii) Metabolic disorders
(iv) Mental retardation
(v) Hereditary haemolytic anaemia
(vi) Sex linked disorder
(vii) Single gene disorder
(viii) Any other (specify)
B. Advanced maternal age (35 years or above)
C. Mother/father/sibling having genetic disease (specify)
D. Other (specify)
10. Laboratory tests carried out (give details)
(i) Chromosomal studies
(ii) Biochemical studies
(iii) Molecular studies
(iv) Preimplantation gentic diagnosis
11. Result of diagnosis
If abnormal give details. Normal/Abnormal
12. Date(s) on which tests carried out.
The results of the Pre-natal diagnostic tests were conveyed to ………………… on …………………
Name,Signature and Registration No.
of the Medical Geneticist/
Director of the Institute
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