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Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse) Rules, 1996

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

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