PRE-NATAL DIAGNOSTIC TECHNIQUES     ( REGULATION AND PREVENTION OF  MISUSE ) ACT 1994.            Form -D [ See rule 9 ( 2 ) ]

Name Address and Registration No, of Genetic Counselling Centre    Record to be Maintained by the Genetic Counselling Centre
1.	Patient's Name	:
2.	Age	:
3.	Husband's / Father's Name	:
4.	Full Address with Tel.No, if any	:
5.	Referred by ( full name address of doctor(s) with registration numbers ( Referral not to be preserved carefully with case papers )	:
6.	Last menstrual period/....Weeks of pregnancy	:
7.	History of genetic/medical disease in the family (specify ) Basic of diagnosis a. [ Clinical ]       b. [ Bio-Chemical ]      c. [ Cyto-genetic ] d. [ Other ] eg. radiological - specify	:
8.	Indication for pre-natal diagnosis A. Prevision child /children with        i. Chromosomal disorders     ii. Metabolic disorders      iii. Congenital anomaly              iv. Mental retardation       v. Haemoglobinopathy             vi. Sex linked disorder     vii. Any other ( specify ) B. Advanced Maternal Age (-35) C. Mother / Father / sibling has genetic disease ( specify ) D. Other ( specify )	:
9.	Procedures advised a. Ultra sound     b. Aminocentesis     c. Chorionic Villi biopsy d. Feotoscopy    d. Foetal skin or organ biopsy e. Condocentesis    f. Any other ( specify )	:
10.	Laboratory tests to be carried out i. Chromosomal studies         ii. Biochemical studies iii. Molecular studies	:
11.	Result of pre-natal diagnostic procedure and specify Normal / Abnormal    ( if abnormal gives details )	:
12.	Was MTP advised	:
13.	Name and address of Genetic clinic to which patient referred	:
14.	Date of commencement and completion of genetic counselling	:
Date :                                                                                               Name, signature and Registration number of the Gynaecologist /                                                                                                                          Radiologist /   Registered Medical Practitioner   *Strike out whichever is not applicable or necessary

 

 

PRE-NATAL DIAGNOSTIC TECHNIQUES ( REGULATION AND PREVENTION    OF MISUSE )   ACT 1994.       Form -E [ See rule 9 ( 3 ) ]

Name Address and Registration No, of Genetic Laboratory    Record to be Maintained by the Genetic Laboratory

1.	Patient's Name	:
2.	Age	:
3.	Husband's / Father's Name	:
4.	Full Address with Tel.No, if any	:
5.	Referred by / Sample sent by  ( full name address of Genetic clinic ( Referral not to be preserved carefully with case papers )	:
6.	Type of sample : Maternal blood / Chorionic villus sample / amniotic fluid / or other foetal tissue ( specify )	:
7.	Specific Indication for pre-natal diagnosis A. Previsions child / Children with       i. Chromosomal disorders   ii. Metabolic disorders      iii. Congenital anomaly           iv. Mental retardation       v. Hereditary  Haemolytic anaemia       vi. Sex linked disorder          vii. Any other ( specify ) B. Advanced Maternal Age (-35) C. Mother/ Father / sibling has genetic disease (specify) D. Other ( specify )	:
8.	Laboratory tests carried out ( give detail )      i. Chromosomal studies    ii. Biochemical studies    iii. Molecular studies	:
9.	Result of pre-natal diagnostic procedure and specify Normal / Abnormal    ( if abnormal gives details )	:
10.	Date(s) on which tests are carried out The results of the pre-natal diagnostic tests were conveyed to_______________________________________________________     on_________________________________________________________________________________________________________
Date :                                                                                              Name, signature and Registration number of the Gynaecologist /                                                                                                                          Radiologist /   Registered Medical Practitioner   *Strike out whichever is not applicable or necessary

 

 

PRE-NATAL DIAGNOSTIC TECHNIQUES ( REGULATION AND PREVENTION OF    MISUSE )     ACT 1994.       Form-F [ See rule 9 ( 4 ) ]

Name Address and Registration No, of Genetic Clinic    Record to be Maintained by the Genetic Clinic

1.	Patient's Name	:
2.	Age	:
3.	Husband's / Father's Name	:
4.	Full Address with Tel.No, if any	:
5.	Referred by  ( full name address of doctor(s) Genetic Counselling Centre ( Referral note to be preserved carefully with case  papers )	:
6.	Last menstrual period/... Weeks of pregnancy	:
7.	History of genetic / medical disease in the family  ( specify )	:
8.	Indication for pre-natal diagnosis A. Previsions child / Children with       i. Chromosomal disorders      ii. Metabolic disorders      iii. Congenital anomaly              iv. Mental retardation       v. Haemoglobinopathy             vi. Sex linked disorder           vii. Any other ( specify ) B. Advanced Maternal Age (35) C. Mother/ Father / sibling has genetic disease (specify) D. Other ( specify )	:
9.	Procedures carried out (with name and registration No. of Gynaecologist / Radiologist / Registered Medical Practitioner Who performed it. a. Ultra-sound         b. Aminocentesis        c. Foetal biopsy d. Chorionic Villi aspiration                      e. Condocentesis f. Any other ( specify )	:
10.	Any complication of procedure - Please specify	:
11.	Laboratory tests recommended      i. Chromosomal studies              ii. Biochemical studies    iii. Molecular studies	:
12.	Result of pre-natal diagnostic procedure and specify Normal / Abnormal ( abnormal detected, if any )	:
13.	Was MTP advised / Conducted	:
14.	Date(s) on which procedures carried out	:
15.	Date on which MTP carried out	:
16.	Date on which consent obtained	:
17.	The result of pre-natal diagnostic procedure were  conveyed to______________________________   on _______________________________
Date :                                                                                                     Name, signature and Registration number of the Gynaecologist /                                                                                                                                  Radiologist /   Registered Medical Practitioner *Strike out whichever is not applicable or necessary

 

  

PRE-NATAL DIAGNOSTIC TECHNIQUES ( REGULATION AND PREVENTION OF   MISUSE )   ACT 1994.       Form -E [ See rule 9 ( 4 ) ]

FORM - G [ See rule 10 ]   Form of Consent   I.......................................................................................wife / daughter of ....................................................... age.....................Year residing at ...................................................................................................................... hereby state that I have been explained fully the probable side effects and after effects of the pre-natal diagnostic procedures.  I wise to undergo the pre-natal diagnostic procedure in my interest to find out the possibility of any abnormality ( i.e., deformity or disorder ) in the child I am carrying. I undertake not to terminate the pregnancy if the pre-natal procedure and any pre-natal tests conducted show the absence of deformity or disorders.  I understand that the sex of the foetus will not be disclosed to me. I understand that breach of this undertaking will make me liable to penalty as prescribed in the Pre-natal Diagnostic Techniques         ( Regulation and Prevention of Misuse ) Act 1994.   Date :                                                                                                                              d Signature ( Patient )     Place : I have explained the contents of the above consent to the patient and her companion. (Name ............................................................................................................................................................. Address........................................................................................................................................................... relationship.............................................................................) in a language she / they understand.   Date :                                                                                                                  Name, Signature and Registration No. of Gynaecologist                                                                                                                                                                                                               Name, address and Registration Number of  the Genetic Clinic