FORM F
[See Proviso to Section 4(3), Rule 9(4) and Rule 10(1A)]
FORM FOR MAINTENANCE OF RECORD IN RESPECT OF PREGNANT WOMAN
BY GENETIC CLINIC/ULTRASOUND CLINIC/IMAGING CENTRE .
1
Name and address of the Genetic /Ultrasound
Clinic/Imaging Centre.-
Registration No.
Patients name and her religion, income& age :
Shreevardhan Xray and ultrasound
clinic at Shreevardhan commercial
complex.
7,Wardha Road, Nagpur
40
Mrs. Sultana Parvez Sheikh
Number of children with sex of each child -
Total: 0
5.
6.
Husbands/Fathers name Full address with Tel. No., if any
Mr. Parvez Sheikh
Mominpura, Gardline, Near Chand
Hotel, Boriyapura Idgah, Nagpur
Ph-9370533788
7
.
Referred by (full name and address of
Doctor(s)/Genetic Counseling Centre
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
Dr Shilpi Sud, Vasantsheela Towers, 4th
Floor, Lokmatbhavan opp. Wardha
road, Nagpur
Dt : 03/11/12 wk: 11
EDD:
10/08/13
NO
10
(c) Cytogenetic
(d) Other (e.g. radiological, ultrasonography etc.
specify) Indication for pre-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)
11.
12
13.
D. Other (specify)
Procedures carried out (with name and registration
no. of registered practitioner who performed it
Male: 0
Not Applicable
Not Applicable
Not Applicable
Ultrasound
NO
NO
Yes- 1 Child Died
NO
NO
NO
NO
NO
NO
Fetal well being and to confirm viability
of reduced
Dr
Rajendrafetus.
Prakashey MMC reg No44552
YES
Non-Invasive
(1)Ultrasound ( specify purpose for which ultrasound is to be done
During pregnancy) [ List of indications for ultrasonography of pregnant
Women are given in the note below]
Invasive
NO
(ii)Amniocentesis
(iii) Chorionic Villi aspiration
(iv) Foetal biopsy
(v) Cordocentesis
(vi) Any other (specify)
Any complication of procedure please specify
NO
Laboratory tests recommended1[3] --NO
(iii) Molecular studies
(iv) Preimplantation genetic diagnosis
Female :0
14.
15.
16.
17.
18.
19.
Result of
(a) pre-natal diagnostic procedure (give details)
(b) Ultrasonography
(Specify abnormality detected, if any).
USG
NORMAL .{Two reduced fetuses which
are not live}
Date(s) on which procedures carried out.
Date on which consent obtained. (In case of invasive)
The result of pre-natal diagnostic procedure were
conveyed to
Was MTP advised/conducted?
Date on which MTP carried out.-
24/01/13
Not applicable
Mrs. Sultana Parvez Sheikh on
24/01/13
NO
MTP not done
Date:
Place
24/01/13
Dr Rajendra Prakashey MMC reg No44552
Nagpur
Name, Signature and Registration number of
the Gynaecologist/radiologist/Director pf the
--------------------------------------------------------------------------------------------------------------------------------------DECLARATION OF PREGNANT WOMAN
I, Mrs. Sultana Parvez Sheikh, declare that by undergoing ultrasonography /image scanning
etc. I do not want to know the sex of my fetus. eh izfrKkiwoZd uewn djrs dh
lksuksxzkQh}kjk eyk xHkZfyax funku djk;ps ukgh- @ eS kiFkiwoZd lwphr djrh gqWz
fd] lksuksxzkQh}kjk fyaxfunku djuk ugh gSA
Signature /thumb of Pregnant woman.
-----------------------------------------------------------------------------------------------------------------------------*strike out whichever is not application or necessary
DECLARATON OF DOCTOR/PERSON CONDUCTING
ULTRASONOGRAPHY/IMAGE SCANNING
I, Rajendra Prakashey (name of the person conducting ultrasonography/image scanning) declare that while
conducting ultrasonography/image scanning on Mrs . Sultana Parvez Sheikh, I have neither detected nor
disclosed the sex of her foetus to any body in any manner.
Dr Rajendra Prakashey.
Name and signature of the person conducting
ultrasonography/image scanning/ Director or owner of
Genetic clinic/ ultrasound clinic/imaging centre.
