FORM F
[See Proviso to Section 4(3), Rule 9(4) and Rule 10(1A)]
FORM FOR MAINTENANCE OF RECORD IN RESPECT OF PREGNANT WOMAN
BY GENETIC CLINIC/ULTRASOUND CLINIC/IMAGING CENTRE .
1
Name and address of the Genetic /Ultrasound
Clinic/Imaging Centre.-
2
3
Registration No.
Patients name and her religion, income& age :
Number of children with sex of each child -
Total: 2
5.
Husbands/Fathers name -
Mr Shailendra Sonavale
6
.
Full address with Tel. No., if any
Juni Mangalwari,CA road,Plot 855
Nagpur
Ph- 9922298237,9021111709
7
.
Referred by (full name and address of
Doctor(s)/Genetic Counselling Centre
Dr Vinay Tule, Eugeniks , Lokmat
square, wardha road, Nagpur
Last menstrual period/weeks of pregnancy
dt : 13/10/12
20/07/13
8
9.
10
11.
12
13.
History of genetic/medical disease in the family
(specify)
Basis of diagnosis:
(a) Clinical
(b) Bio-chemical
(c) Cytogenetic
(d) Other (e.g.radiological, ultrasonography etc.
specify) 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) Single gene disorder
(viii) Any other (specify)
B. Advanced maternal age (35 years)
C. Mother/father/sibling has genetic disease
(specify)
D. Other (specify)
Male: 1
Female : 1
wk: 24
EDD:
Not Applicable
Not Applicable
Not Applicable
Ultrasound
NO
NO
NO
NO
NO
NO
NO
2 Abortion {VESICULAR MOLE}
NO
NO
Not applicable
Dr Rajendra Prakashey MMC reg No44552
Non-Invasive
YES
(1)Ultrasound ( specify purposefor which ultrasound is tobe done
During pregnancy) [ List of indications for ultrasonography of pregnant
Women are given in the note below]
Procedures carried out (with name and registration
no. of registered practitioner who performed it
Invasive
(ii)Amniocentesis
(iii) Chorionic Villi aspiration
(iv) Foetal biopsy
(v) Cordocentesis
(vi) Any other (specify)
Any complication of procedure please specify
Laboratory tests recommended1[3] ---
YES
(i) Chromosomal studies
YES
(ii) Biochemical studies
(iii) Molecular studies
(iv) Preimplantation genetic diagnosis
14.
Shreevardhan Xray and ultrasound
clinic at Shreevardhan commercial
complex. 7,Wardha Road, Nagpur
40
Mrs Rekha Shailendra Sonavale
Hindu, 34yr
Result of
1
CVS- DOWNS SYNDROME
NO
YES
(a) pre-natal diagnostic procedure (give details)
USG / INVASIVE-CVS:report sent for
exam on
04/04/13
Invasive report normal/ abnormal
Dt
Awaited
}
NORMAL
18.
(b) Ultrasonography
(specify abnormality detected, if any).
Date(s) on which procedures carried out.
Date on which consent obtained. (In case of
invasive)
The
result of pre-natal diagnostic procedure were
conveyed to
Was MTP advised/conducted?
19.
Date on which MTP carried out.-
MTP not done
Date: 04/04/13
Dr Rajendra Prakashey MMC reg No44552
15.
16.
17.
Place : Nagpur
04/04/13
04/04/13
Mrs Sweety Yogesh Mandaogade on
04/04/13
NO
Name, Signature and Registration number of
the Gynaecologist/radiologist/Director pf the
--------------------------------------------------------------------------------------------------------------------------------------DECLARATION OF PREGNANT WOMAN
I, Mrs Rekha Shailendra Sonavale, declare that by undergoing ultrasonography /image
scanning etc. I do not want to know the sex of my foetus. eh izfrKkiwoZd uewn djrs dh
lksuksxzkQh}kjk eyk xHkZfyax funku djk;ps ukgh- @ eS kiFkiwoZd lwphr djrh gqWz
fd] lksuksxzkQh}kjk fyaxfunku djuk ugh gSA
Signature /thumb of Pregnant woman.
-----------------------------------------------------------------------------------------------------------------------------*strike out whichever is not application or necessary
DECLARATON OF DOCTOR/PERSON CONDUCTING
ULTRASONOGRAPHY/IMAGE SCANNING
I, Rajendra Prakashey (name of the person conducting ultrasonography/image scanning) declare that while
conducting ultrasonography/image scanning on Mrs Rekha Shailendra Sonavale, I have neither
detected nor disclosed the sex of her foetus to any body in any manner.
Dr Rajendra Prakashey.
Name and signature of the person conducting
ultrasonography/image scanning/ Director or owner of
genetic clinic/ ultrasound clinic/imaging centre.
