Service Description
Application Form
Apply For Service
FORM-F
[See provison 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/ULTRASQUND CLINIC/IMAGING CENTRE
Section
UBIN
*
---pendingNotExist---
---pendingEnd--- ---pendingExist---
---pendingEnd---
Select Office
*
---pendingNotExist---
Please Select
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
---pendingEnd--- ---pendingExist---
---pendingEnd---
Section A : To be filled for all diagnostic Procedures / Tests
1.Name and complete address of Genetic Clinic /Ultrasound Clinic Imaging centre:
2.Registration No. (Under PC & PNDT Act, 1994).
3.Patient Name
Age
4.Total Number of living children:
4.(a) Number of living Sons with age of each living son (in years or months):
4.(b) Number of living Daughters 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 Doctor(s) Genetic Counselling Centre): (Referral Slips to be preserved carefully with Form F)
7(b) Self-Referral by Gynaecologist/ Radiologist/ Registered Medical Practitioner conducting the diagnostic procedures : (Referral note with indications and case papers of the patient to be preserved with Form F) (Self-referrel does not mean a client coming to a clinic and requesting for the test or the relative/s requesting for the test of a pregnant woman)
8 Last menstrual period or weeks of pregnancy:
Section B : To be filled in for performing non-invasive diagnostic procedures / Tests only
9. Name of the doctor performing the procedure/s :
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 only be performed when indicated. The following is the representative list of indications for ultrasound during pregnancy (Put a "Tick" against the appropriate indications 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 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.
x. Detection of chromosomal abnormalities, fetal structural defects and other abnormalities and their follow-up.
xi. To evaluate fetal presentation and position.
xii. Assessment of liqour amnii.
xiii. Preterm labour / preterm premature rupture of membrances.
xiv. Evaluation of placental position, thickness, grading and abnormalities (placenta praevia, retro placental hemorrhage, abnormal adherence etc.).
xv. Evaluation of umbilical cord -- presentation, insertion, nuchal encencliment, numbers 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. Color flow mapping and duplex Doppler studies.
xix. Ultrasound guided procedures such as medical termination of pregnancy, external cephalic version etc. and their follow-up.
xx. Adjunct to diagnostic and theraputic 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). Ultrsound (Impotant Note: Ultrasound is not indicated/advised/performed to determE the sex of Futus except for diagnosis of sex linked diseases such as Duchene Muscular Dystrophy, Hemophilia A & B etc.)
(ii). Any other (Specify)
If other (Please specify)
12.Date on which declaration of pregnant woman/person was obtained :
13.Date on which procedures carried out:
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
Conveyed On Date
16 Any indication for MTP as per the abnormality detected in the diagnostic procedures/ tests
Section C : To be filled for performing invasive Procedures/Tests only
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 the appropriate basis of diagnosis)
(a) Clinical
(b) Bio-chemical
(c) Cytogenetic
(d) Other (e.g, radiological, ultrasonography etc -specify)
19.Indication/s for the diagnosis procedure("Tick" on the appropriate basis of indications)
A)Previous child/children with :
i.Chromosomal disorders
ii.Metabolic disorders
iii.Congenital anomaly
iv.Mental Disability
v.Haemoglobinopathy
vi.Sex linked disorders
vii. Single gene disorder
viii. Any other (Specify)
If other (Please specify)
B) Advanced maternal age (35 years)
C. Mother/father/sibling has genetic disease (specify)
D) Others Specify
20. Date on which consent of pregnant woman / person was obtained in Form G prescribed in PC & PNDT Act, 1994
21. Invasive procedures carried out("Tick" on the appropriate basis of indications)
i.Amniocentesis
ii.Chorionic Villi aspiration
iii.Fetal biopsy
iv.Cordocentesis
v.Any other (Specify)
If other (Please specify)
22. Any complication/s of invasive procedure (specify):
23. Additional tests recommended (Please mention if applicable):
i.Chromosomal studies
ii.Biochemical studies
ii.Molecular studies
iv.Pre-implantation gender diagnosis
v.Any other (Specify)
If other (Please specify)
24. Result of the procedures/ Tests carried out (report in brief of the invasive tests/procedures carried out)
25. Date on which procedures carried out:
26. The result of pre-natal diagnostic procedures was conveyed to
Conveyed On Date
27. Any indication for MPT as per the abnormality detected in the diagnostic procedures / tests
Applicant details for notifications
Applicant Full Name :
*
---pendingNotExist---
---pendingEnd--- ---pendingExist---
---pendingEnd---
Mobile Number :
*
---pendingNotExist---
---pendingEnd--- ---pendingExist---
---pendingEnd---
EMail id :
Camera
Video stream not available.
Image
Image Captured. Please click OK to upload.