Pre-Natal Diagnostic Techniques Rules, 1996 - FORM F

Email Print This Page bookmark
Font : A-A+

FORM F - NAME, ADDRESS AND REGISTRATION No. OF GENETIC CLINIC RECORD TO BE MAINTAINED BY THE GENETIC CLINIC
[See Rule 9(4)]

 1. Patient’s name

2. Age

3. Husband’s/Father’s name

4. Full address with Tel. No., if any

5. Referred by (full name and address of Doctor(s)/Genetic Counselling Centre (Referral note to be preserved carefully with case papers)

6. Last menstrual period/weeks of pregnancy

7. History of genetic/medical disease in the family (specify) Basis of diagnosis:

(a) Clinical

(b) Bio-chemical

(c) Cytogenetic

(d)Other (e.g.radiological-specify)

 8. 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)    Any other (specify)

B. Advanced maternal age (35 years)

C. Mother/father/sibling has genetic disease (specify)

D. Other (specify)

9. Procedures carried out (with name and registration No. of Gynaecologist/Radiologist/Registered Medical Practitioner) who performed it.

            (i)  Ultrasound

            (ii) Amniocentesis

            (iii) Chorionic Villi aspiration

            (iv) Foetal biopsy

            (v) Cordocentesis

           (vi)Any other (specify)

 10.Any complication of procedure – please specify

 11.Laboratory tests recommended[3]

             (i)  Chromosomal studies

             (ii)  Biochemical studies

            (iii)  Molecular studies

 12. Result of pre-natal diagnostic procedure and specify Normal/Abnormal abnormality detected, if any.

 13. Was MTP advised/conducted?

 14. Date(s) on which procedures carried out.

 15. Date on which MTP carried out.

 16. Date on which consent obtained.

 17. The result of pre-natal diagnostic procedure were conveyed to …………………………….on …………………………

                                                         Name, Signature and

                                                         Registration number of the

                                                         Gynaecologist/Radiologist/

                                                         Registered Medical Practitioner

Date:

Place

Post a Comment

Comments should be on the topic and should not be abusive. The editorial team reserves the right to review and moderate the comments posted on the site.
Notify me when reply is posted
I agree to the terms and conditions
pankajtver76 

What is the provision under PC PNDT ACT for Doctors who is exclusively doing Echocardiography only: 1. Whether they also required PNDT Registration for Echocardiography. 2. And what about six months ultrasound training program for such Doctors [while six months training program is focusing on abdominal and pelvic region only]. In this condition how this training program is going to be beneficial for them. And is it making any sense that Doctors who is practicing cardiology and doing Echocardiography getting training of pelvic and abdominal region, while these areas are not of their concerns at all.

mamta_thakur000 

Can diagnostic center be started by person other than doctors, i hv completed bsc nursing n post graduation in hospital administration am i eligible to start a diagnostic center or a nursing home plz rep

kamlesh_kumar 

Please send a list of Govt. / MCA / UGC recognized centres that atre approved for training of sonologisets / doctors to conduct USG under the PNDTA act.

anil1963 

In pndt act , rule 13 about change of equipment in advance of 30 days from such change should be intimated to DAA. Wether this intimation of 30 days is from purhase of machine or installation of machine ?
Kindly tell me.

dmj_71 

please show how to fill the form

Medindia Newsletters

Subscribe to our Free Newsletters!

Terms & Conditions and Privacy Policy.

Find a Doctor
Advertisement

Stay Connected

  • Available on the Android Market
  • Available on the App Store

Facebook