Pre-Natal Diagnostic Techniques Rules, 1996 - FORM D

FORM D - NAME, ADDRESS AND REGISTRATION No. OF GENETIC COUNSELLING CENTRE RECORD TO BE MAINTAINED BY THE GENETIC COUNSELLING CENTRE

[See rule 9(2)]

 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) with registration No.(s) (Referred 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)

 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. Others (specify)

9. Procedure advised

            (i)  Ultrasound

            (ii) Amniocentesis

            (iii) Chorionic villi biopsy

            (iv) Foetoscopy

            (v) Foetal skin or organ biopsy

            (vi) Cordocentesis

            (vii) Any other (specify)

10.Laboratory tests to be carried out

             (i)  Chromosomal studies

            (ii)   Biochemical studies

           (iii)   Molecular studies

11. Result of pre-natal diagnosis

            If abnormal give details.                          Normal/Abnormal

12. Was MTP advised?

13. Name and address of Genetic Clinic* to which patient referred.

14. Dates of commencement and completion of genetic counseling.

           Name, Signature and Registration No. of the 

Medical Geneticist/Gynaecologist/Paediatrician

Date: