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

Section A : To be filled in for all Diagnostic Procedures/Tests SECTION C: To be filled for performing invasive Procedures/ Tests only
1.Name and complete address of Genetic Clinic/Ultrasound Clinic/Imaging centre: 17. Name of the doctor/s performing the procedure/s:___________________________
_______________________________________________________________________ 18. History of genetic/medical disease in the family (specify):_____________________
_______________________________________________________________________ Basis of diagnosis (“Tick” on appropriate basis of diagnosis):
2.Registration No(Under PC & PNDT ACT, 1994) ________________________________ (a) Clinical (b) Bio-chemical
3.Patient’s Name ________________________________________________Age______ (c) Cytogenetic (d) other (e.g. radiological, ultrasonography etc.-specify)
4.Total Number of Living children:____________________________________________
(a) Number of Living sons with age of each living son(in years or months): 19. Indication/s for the diagnosis procedure (“Tick” on appropriate indication/s):
___________________________________________________________ A. Previous child/children with:
(b) Number of living Daughters with age of each living daughter (in years of months): (i) Chromosomal disorders (ii) Metabolic disorders
__________________________________________________________ (iii) Congenital anomaly (iv) Mental Disability
5.Husband’s /wife’s /Father’s /Mother’s Name : (v) Haemoglobinopathy (vi) Sex linked disorders
_______________________________________________________________________ (vii) Single gene disorder (viii) Any other (specify)
6.Full postal address of the patient’s with Contact Number, if any__________________ B. Advanced maternal age (35 years)
_______________________________________________________________________ C. Mother/father/sibling has genetic disease (specify)
7.(a) Referred by ( Full Name and address of Doctor(s) /Genetic counselling Centre) : D. Other (specify) _______________________________________________________
_______________________________________________________________________ 20. Date on which consent of pregnant woman / person was obtained in Form G
_______________________________________________________________________ prescribed in PC&PNDT Act, 1994:__________________________________________
(Referral slips to be preserved carefully with Form F) 21. Invasive procedures carried out (“Tick” on appropriate indication/s)
(b) Self- Referral by Gynaecologist/Radiologist/Registered Medical Practitioner i. Amniocentesis ii. Chorionic Villi aspiration
conducting the diagnostic procedures: ______________________________________ iii. Fetal biopsy iv. Cordocentesis
(Referral note with indications case papers of the patients to be preserved with Form F) v. Any other (specify)
(Self –referral does not mean a client coming to a clinic and requesting for the test or 22. Any complication/s of invasive procedure(specify)__________________________
the relatives requesting for the test of pregnant woman) ______________________________________________________________________
8. Last menstrual period /weeks of pregnancy_____________________________ 23. Additional tests recommended (Please mention if applicable)
Section B : To be filled in for performing non-invasive diagnostic (i) Chromosomal studies (ii) Biochemical studies
Procedures/ Tests only) (iii) Molecular studies (iv) Pre-implantation gender diagnosis
9.Name of the doctor performing the procedure/s: (v) Any other (specify)
______________________________________________________________________ 24. Result of the Procedures/ Tests carried out (report in brief of the invasive tests/
10.Indication/s for diagnosis procedure ___________________________________ procedures carried out)___________________________________________________
(specify with reference to the request made in the referral slip or in a self- referral note) 25. Date on which procedures carried out:____________________________________
(Ultrasonography parental diagnosis during pregnancy should only be performed when 26. The result of pre-natal diagnostic procedures was conveyed to ________on______
indicated. The following is the representative list of indication for ultrasound during 27. Any indication for MTP as per the abnormality detected in the diagnostic
pregnancy.(Put a “Tick against the appropriate indication/s for ultrasound) procedures/tests_________________________________________________________
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 following
contraceptive failure/MTP Date: Name, Signature and Registration Number with Seal of the
v. Vaginal bleeding/leaking. Place: Gynaecologist/Radiologist/Registered Medical Practitioner
vi. Follow-up of cases of abortion. performing Diagnostic Procedure/s
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 chromosomal abnormalities, fetal structural defects and other
SECTION D: Declaration
abnormalities and their follow-up.
xi. To evaluate fetal presentation and position. DECLARATION OF THE PERSON UNDERGOING
xii. Assessment of liquor amniixiii. PRENATAL DIAGNOSTIC TEST/ PROCEDURE
xiii Preterm labor / preterm premature rupture of membranes. I, Mrs./Mr.__________________________________________ declare that by
xiv. Evaluation of placental position, thickness, grading and abnormalities (placenta undergoing __________________________ Prenatal Diagnostic Test/ Procedure. I do
praevia, retro placental hemorrhage, abnormal adherence etc.). not want to know the sex of my foetus.
xv. Evaluation of umbilical cord – presentation, insertion, nuchal encirclement, number
of vessels and presence of true knot.
xvi. Evaluation of previous Caesarean Section scars. Date: Signature/Thump impression of the person undergoing
xvii. Evaluation of fetal growth parameters, fetal weight and fetal well being. the Prenatal Diagnostic Test/ Procedure
xviii. Color flow mapping and duplex Doppler studies.
xix. Ultrasound guided procedures such as medical termination of pregnancy, external In Case of thumb Impression:
cephalic version etc. and their follow-up. Identified by (Name)___________________________________Age:______ Sex:_____
xx. Adjunct to diagnostic and therapeutic invasive interventions such as chorionic villus Relation (if any):_________________________________________________________
sampling (CVS), amniocenteses, fetal blood sampling, fetal skin biopsy, amnio-infusion, Address & Contact No.:____________________________________________________
intrauterine -infusion, placement of shunts etc. _______________________________________________________________________
xxi. Observation of intra-partum events. Signature of a person attesting thumb impression: _________________Date:_________
xxii. Medical/surgical conditions complicating pregnancy.
xxiii. Research/scientific studies in recognized institutions.
DECLARATION OF DOCTOR/ PERSON CONDUCTING
11. Procedures carried out (Non-Invasive) (Put a “Tick” on the appropriate procedure)
PRE NATAL DIAGNOSTIC PROCEDURE/TEST
i. Ultrasound
I,_______________________________(name of the person conducting
(Important Note: Ultrasound is not indicated/advised/performed to determine the sex
ultrasonography / image scanning) declares that the while conducting ultrasonography
of fetus except for diagnosis of sex-linked diseases such as Duchene Muscular
/image scanning on Ms/Mr_________________________________________ (name of
Dystrophy, Hemophilia A& B etc.)
the pregnant woman or the person undergoing pre natal diagnostic procedure/test), I
ii. Any other (specify)_________________________________________
have neither detected nor disclosed the sex of her foetus to anybody in any manner.
12. Date on which declaration of pregnant woman/ person was obtained :__________
13. Date on which procedures carried out:_____________________________________
Date: _______________ Signature:______________________
14. Result of the non-invasive procedure carried out (report in brief of the test including
______________________________
ultrasound carried out)____________________________________________________
______________________________________________________________________
15. The result of pre-natal diagnostic procedures was conveyed to
Name in Capitals, Registration Number with Seal of
_____________________________on_______________________________________
the Gynaecologist/Radiologist/Registered Medical Practitioner
16. Any indication for MTP as per the abnormality detected in the diagnostic
Conducting Diagnostic procedure.
procedures/tests ________________________________________________________

Date: Name, Sign and Registration Number with Seal of the Gynaecologist
Place: /Radiologist /Registered Medical Practitioner performing Diagnostic Procedure/s.