FORM - F
Refer proviso to section (4) rules 9(4) and 10(1A)
FORM FOR MAINTENANCE OF RECORDS IN CASE OF PRENATAL DIAGNOSTIC TEST /
PROCEDURE BY GENETIC CLINIC/ULTRASOUND CLINIC/IMAGING CENTRE
Section A. To be filled in for all Diagnostic Procedure Tests
1. Name and complete address of the Genetic Clinic/Ultrasound Clinic/Imaging Centre:
New Medicare Diagnostic Centre
Durgapur Road, Vill + PO – Barjorp, Dist – Bankura, West Bengal, PIN – 722202
2. Registration No. (Under PC & PNDT Act 1994):
L/2024/000094
3. Patient's Name: ____________________________
4. A. Number of living Children: ____________________________
B. Number of living Sons with age of each living son (in years or months):
____________________________
C. Number of living Daughter with age of each living daughter (in years or months):
____________________________
5. Husband's/Wife's/Father's/Mother's Name: ____________________________
6. Full Postal address of the patient with contact Number, if any: ____________________________
7. A. Referred by [Full name and & address of doctors] / Genetic Counseling Centre:
____________________________
B. Self-Referral by Gynecologist / Radiologist / Registered Medical Practitioner
Conducting the diagnostic procedure:
(Referral slips to be preserved carefully with form F)
(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 the test or to the
relatives/requesting for the test of a pregnant woman)
8. Last Menstrual period or weeks of pregnancy: ____________________________
9. Name of the doctor performing the procedure/s: ____________________________
Indication/s for diagnostic procedures (specify with reference to the request made in the
referral slip or in a self-referral note):
Following is the representative list of indications for ultrasound during pregnancy. Put
"Tick" against the appropriate indication/s:
i. Routine scan for uterine and/or ectopic pregnancy and confirm viability
ii. Estimation of gestational age (dating)
iii. Determination of number of foetuses and their chorionicity
iv. Suspected pregnancy with IUCD in-situ or suspected pregnancy following 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
10. Substituted vide GSR 109(E), dt. 14-2-2003, w.e.f. 14-2-2003:
x. Detection of chromosomal abnormalities, fetal structural defects and other
abnormalities and their follow-up
xi. Evaluation of 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 placenta hemorrhage, abnormal adherence etc.)
xv. Evaluation of umbilical cord presentation, insertion, nuchal encirclement, number of
vessels and presence of true knot
xvi. Evaluation of previous Caesarean Section scars
xvii. Evaluation of fetal growth parameters, fetal weight and fetal well being
xviii. Follow-up of twin pregnancy
xix. Evaluation of fetal anomalies (use Doppler studies etc.)
xx. Ultrasound guided procedures such as medical termination of pregnancy, external
cephalic version etc. and their follow-up
xxi. Advanced diagnostic and therapeutic invasive interventions such as chorionic villus
sampling (CVS), amniocenteses, fetal blood sampling, fetal skin biopsy, amino-infusion,
intrauterine infusion, placement of shunts etc.
xxii. Detection of intra-partum events
xxiii. Medical/surgical condition complicating pregnancy
xxiv. Research/scientist studies in recognized institutions
11. Procedure carried out (Non-Invasive) Put a "Tick" on the appropriate procedures:
i. Ultrasound
(Important Note: Ultrasound is not indicated/advised/performed to determine the sex of
fetus except for diagnosis of sex-linked disorders such as Duchene Muscular Dystrophy,
Hemophilia A & B etc.)
ii. Any other (specify): ____________________________
