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
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:
8. Indication for pre-natal diagnosis
A.Previous child/children with:
(i) Chromosomal disorders
(ii) Metabolic disorders
(iii) Congenital anomaly
(iv) Mental retardation
(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.
(iii) Chorionic Villi aspiration
(iv) Foetal biopsy
(vi)Any other (specify)
10.Any complication of procedure – please specify
11.Laboratory tests recommended
(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