FORM F
[See Proviso to Section 4(3), rule 9(4) and rule 10(1A)]
FORM FOR MAINTENANCE OF RECORD IN CASE OF PRENATAL DIAGNOSTIC TEST /
PROCEDURE BY GENETIC CLINIC/ULTRASOUND CLINIC/IMAGING CENTRE
Section A: To be filled in for all Diagnostic Procedures/Tests
1. Name and complete address o f Genetic Clinic/Ultrasound Clinic/Imaging centre:_Ghadge
Hospital, 7,Kirti Housing Society, A/P- Nagthane, Tal & Dist- Satara (415519 )
2. Registration No. ( Under PC& PNDT Act, 1994) :- SAT/STR/263/2006 .
3. Patient’s name ________________________________________ _Age- .
4. Total Number of living children :
(a) Number of living Sons with age of each living son (in years or months):
(b) Number of living Daughters with age of each living daughter (in years or month s) :
5. Husband’s /Wife’s/ Father’s / Mother’s Name :____ ________________ _______________
6. Full postal address of the patient with Contact Number, if any_________ _
___________________________________________________________Mob No- _____
7. (a) Referred b y (Full name and address of Doctor(s)/ Genetic Counseling centre) .
_________________________________________________________ ______ __
(Referral slips to be preserved carefully with Form F)
(b) Self-Referral by Gynecologist/Radiologist/Registered Medical Practitioner conducting
the diagnostic procedures: _Referral note & case paper attached.
( Referral note with indications and case papers of the patient to be preserved with Form F)
(Self-referral does not mean a client coming to a clinic and requesting for the test or the relative/s requesting for the test of a preg nant woman)
8. Last menstrual period or weeks of pregnancy :LMP :- / /201 GA :- wk D
Section B: To be filled in for performing non-invasive diagnostic Procedures/ Tests only
9. Name of the do ctor performing the procedure/s :- Dr. Vikas Tukaram Ghadge
10. Indication/s for diagnosis procedure _________________________ _____ _
(specify with reference to the request made in the referral slip or in a self -referral note )
(Ultrasonography prenatal diagnosis during pregnancy should o nly be performed when indicated. The
follo wing is the representative list of indications for ultrasound during pregnancy.
(Put a “Tick” against the appropriate indication/s for ultrasound)
i. To diagnose intra-uterine and/or ectopic pregnancy and confirm viability.
ii. Estimation of gestational age (dating).
iii. Detection of number of fetuses and their chorionicity.
iv. Suspected pregnancy with IUCD in-situ or suspected pregnancy fo llowing contraceptive failure/MTP failure.
v. Vaginal bleeding/leaking.
vi. Follow-up of cases of abortion.
vii. Assessment of cervical canal and diameter of internal os.
viii Discrepancy between uterine size and period of amenorrhea.
ix. Any suspected adenexal or uterine pathology/abnormality.
x. Detection of chro mosomal abnormalities,fetal structural defects and other abnormalities and their follow-up.
xi. To evaluate fetal presentation and position.
xii. Assessment of liquor amnii.
xiii Preterm labor / preterm premature rupture of membranes.
xiv Evaluation of placental position, thickness, grading and abnormalities (placenta praevia, retro
placental hemorrhage, abnormal adherence etc.).
xv. Evaluation of umbilical co rd – presentation, insertio n, nuchal encirclement, number of vessels and
presence of true knot.
xvi Evaluation of previous Caesarean Section scars.
xvi Evaluation of fetal growth parameters, fetal weight and fetal well being.
xviii Color flow mapping and duplex Doppler studies.
xix. Ultrasound guided procedures such as medical termination o f p regnancy, external cephalic version
etc. and their follow-up.
xx. Adjunct to diagnostic and therapeutic invasive interventions such as chorionic villus sampling (CVS),
amniocenteses, fetal blood sampling, fetal skin biopsy, amnio-infusion, intrauterine infusion,
placement of shunts etc.
xxi. Observation of intra-partum events.
xxii. Medical/surgical conditions complicating pregnancy.
xxiii. Research/scientific studies in recognized institutions.
11. Procedures carried out (Non-Invasive) (Put a “Tick” on the appropriate procedure)
i. Ultrasound ( Important Note: Ultrasound is no t indicated/advised/performed to determin e the sex of
fetuse except for dignosis o f sex-linked diseases such as Duchene Muscular Dystrophy, Hemophilia A& B etc.)
ii. Any other (specify) ____ ______
12. Date on which declaration of pregnant woman/ person was obtained :- / /2015
13. Date on which procedures carried out :- / /2015
14. Result of the non-invasive procedure carried out (report in brief of th e test including ultrasoun d carried out)
__________________________________________ ____________
15. The result of pre-natal diagnostic procedures was conveyed to ____________ _o n / /2015
16. Any indication for MTP as per the abnormality detected in the diagnostic procedures/ test:-
________ ___________________________________________________________
Date:- / /2015
Palce :- Nagthane
Name signature,and Registration Number with
Seal of the gynaecologist/Radiologist/Registered
Medical Practitioner performing Diagnostic Procedure/s
SECTION C: To be filled for performing invasive Procedures/ Tests only
Coloumn Sr. No 17 to 27 – Not APPLICABLE
SECTION D: Declaration
DECLARATION OF THE PERSON UNDERGOING PRENATAL DIAGNOSTIC TEST/ PROCEDURE
I/मी, Mrs._________________________________________ _ declare that b y undergoing
ultrasonography/ image scanning Prenatal Diagnostic Test/ Procedure. I do not want to know the sex of my
foetus.
/नमूद करते की सोनोग्राफी करताना मला माझ्या गर्भाचे लिंग जाणून घेण्याची इच्छा नाही.
Date: / /2015
Signature/Thump impression of the person
undergoing the Prenatal Diagnostic Test/ Procedure
In Case of thumb Impression:
Identified by (Name)______ ______________________ _____ _ _____Age:______Sex:_ ______
Relation (if any ):_____ _______Address & Contact No.:___________ _____________________
_____________________ ____________________________________ ____________________
Signature of a person attesting thumb impression : ________ __________ Date :- / /2015
DECLARATION OF DOCTOR/PERSON CONDUCTING PRE NATAL DIAGNOSTIC PROCEDURE/TEST
I, Dr.Vikas Tukaram Ghadge (name of the person conducting ultrasonography/image scanning) declare that while
conducting ultrasonography/image scanning on Mr . .
.(name of the pregnant woman or the person undergoing pre natal
diagnostic procedure/ test), I have neither detected nor disclosed the sex o f her fetus to anybody in any manner.
Signature: ____________________________
Date: / /2015
Name in Capitals, Registration Numb er with Seal of the
Gynaecologist /Radiologist/Registered Medical Practitioner
Conducting Diagnostic procedure
