Service Description
Application Form
Apply For Service
FORM-D
See rule 9(2)
Form for Maintenance of Records by the Genetic Counselling Center
Section
UBIN
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Select Office
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BAKSA
BARPETA
Biswanath
BONGAIGAON
CACHAR
CHARAIDEO
CHIRANG
DARRANG
DHEMAJI
DHUBRI
DIBRUGARH
DIMA HASAO
GOALPARA
GOLAGHAT
HAILAKANDI
HOJAI
JORHAT
KAMRUP
KAMRUP METRO
KARBI ANGLONG
KARIMGANJ
KOKRAJHAR
LAKHIMPUR
MAJULI
MARIGAON
NAGAON
NALBARI
SIVASAGAR
SONITPUR
SOUTH SALMARA MANCACHAR
TINSUKIA
UDALGURI
WEST KARBI ANGLONG
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1. Name and address of Genetic Counselling centre.
Name
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Address Line 1
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Address Line 2
Address Line 3
Country
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India
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Central African Republic
Cape Verde
Chad
Chile
China
Colombia
Comoros
Conga
Costa Rica
Côte d Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Korea,Democratic People s Republic of
Congo, the Democratic Republic of the
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Tajikistan
Thailand
The former Yugoslav Republic of Macedonia
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United Republic of Tanzania
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic of
Viet Nam
Yemen
Zambia
Zimbabwe
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State
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ANDAMAN AND NICOBAR ISLANDS
ANDHRA PRADESH
ARUNACHAL PRADESH
ASSAM
BIHAR
CHANDIGARH
CHHATTISGARH
DADRA AND NAGAR HAVELI
DAMAN AND DIU
DELHI
GOA
GUJARAT
HARYANA
HIMACHAL PRADESH
JAMMU AND KASHMIR
JHARKHAND
KARNATAKA
KERALA
LAKSHADWEEP
MADHYA PRADESH
MAHARASHTRA
MANIPUR
MEGHALAYA
MIZORAM
NAGALAND
ODISHA
PUDUCHERRY
PUNJAB
RAJASTHAN
SIKKIM
TAMIL NADU
TELANGANA
TRIPURA
UTTARAKHAND
UTTAR PRADESH
WEST BENGAL
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District
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Postal / Zip Code
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2. Registration No. : (Under PC & PNDT Act 1994)
3. Patients name :
4. Age
5. Husbands / Fathers name :
6. Full postal address of the patient with contact number if any
7. Referred by (Full name and address of Doctor(s) with registration No.(s) (Referral note to be preserved carefully with case papers).
8. Last menstrual period/ weeks of pregnancy :
9. History of genetic/medical disease in the family(specify) - Basis of diagnosis.: (a) Clinical : (b) Bio-chemical : (c) Cytogenetic : (d) Other (e.g. radiological, ulrasonography ) :
10. Indication for per-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 or above) :
C. Mother /father/sibling having genetic disease (specify) :
D. Others (specify) :
11. Procedure advised. (i) Ultrasound : (ii) Amniocentesis : (iii) Chorionic villi biopsy : (iv) Foetoscopy : (v) Foetal skin or organ biopsy : (vi) Cordocentesis : (vii) Any other (specify) :
12. Laboratory tests to be carried out. (i) Chromosomal studies : (ii) Biochmical studies : (iii) Molecular studies : (iv) Preimplantation genetic diagnosis :
13. Result of pre-natal diagnosis :
Normal
Abnormal
If abnormal (give details) :
14. Was MTP advised :
15. Name and address of Genetic Clinic* to which patient is referred.
16.Dates of Commencement and completion of genetic counselling
Applicant details for notifications
Applicant Name :
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Mobile Number :
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EMail id :
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