FORM – F
[See proviso to Section 4(3), rule 9(4) and rule 10(1A)]
(New amended on 4th February, 2014 notified on 31st January 2014)
FORM FOR MAINTENANCE OF RECORD IN CASE OF PRENATAL DIAGNOSTIC TEST / PROCEDURE BY
GENETIC CLINIC / ULTRASOUND CLINIC / IMAGING CENTRE
SECTION A: To be filled in 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’s name ___________________________________________ Age ____________________________
4. Total Number of living children: _____________________________________________________________
a) Number of living Sons with age of each living son (in years or months): _______________________
_________________________________________________________________________________
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)
(b). Self-Referral by Gynaecologists/Radiologists/Registered Medical Practitioner conducting the diagnostic
procedures: __________________________________________________________________________________
(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 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)
1
(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
indication/s 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 liquor amnii.
xiii. Preterm labor/preterm premature rupture of membranes.
xiv. Evaluation of placental position, thickness, grading and abnormalities (placenta praevia, retro placental
haemorrhage, 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. 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 therapeutic invasive interventions such as chorionic villus sampling (CVS),
amniocenteses, feel 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). Ultrasound
(Important Note: Ultrasound is not indicated/advised/performed to determine the sex of fetus except
for diagnosis of sex-linked diseases such as Duchene Muscular Dystrophy, Hemophilia A & B et.)
ii). Any other (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 _________________ on __________________
16. Any indication for MTP as per the abnormality detected in the diagnostic procedures/tests ________________
________________________________________________________________________________________
2
Date: ___________________ Name, Signature and Registration Number with Seal of the
Gynaecologist/Radiologist/Registered Medical
Place: ___________________ Practitioner performing Diagnostic Procedure/s
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 appropriate basis of diagnosis):
(a) Clinical (b) Bio-chemical
(c) Cytogenetic (d) Other ([Link], ultrasonography etc.- specify)
19. Indication/s for the diagnosis procedure (“Tick” on appropriate indication/s):
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)
B. Advanced maternal age (35 years)
C. Mother/father/sibling has genetic disease (specify)
D. Other (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 appropriate indication/s)
i. Amniocentesis ii. Chorionic Villi aspiration
iii. Fetal biopsy iv. Cordocentesis
v. Any other (specify)
22. Any complication/s of invasive procedure (specify) _______________________________________________
________________________________________________________________________________________
23. Additional tests recommended (please mention if applicable)
(i). Chromosomal studies (ii). Biochemical studies
(iii). Molecular studies (iv). Pre-implantation gender diagnosis
(v). Any other (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 ____________________ on _______________
27. Any indication for MTP as per the abnormality detected in the diagnostic procedures/tests ________________
________________________________________________________________________________________
3
Date: ___________________ Name, Signature and Registration Number with Seal of the
Gynaecologist/Radiologist/Registered Medical
Place: ___________________ Practitioner performing diagnostic Procedure/s
SECTION D: Declaration
DECLARATION OF THE PERSON UNDERGOING PRE-NATAL DIAGNOSTIC TEST/PROCEDURE KA
JINGMYNJURJONG KA BRIEW KA BAN LEH IA KA TEST SHWA BAN KHA IA I KHUNLUNG
I, Mrs. / Mr. __________________________________________________________ declare that by undergoing
__________________________________________ Pre-Natal diagnostic test/procedure. I do not want to know the
sex of my foetus.
Nga, Ka/U _____________________________________________________ nga mynjur ba da ka jingleh ia kane ka
test shwa ban kha khunlung, ngam ban tip ia ka jinglong shynrang ne kynthei I khunlung ha kpoh.
Date:- Signature / thumb impression of the person
Tarik:- undergoing the pre-natal Diagnostic Test/procedure
Jingshonti / Jingsoi ka nongpun khun
In case of thumb impression
Na ka bynta ba shu shonti.
Identified by (name) …………………………………………………… age ……………… sex ……………………….
Lah pynshisha da (Kyrteng) ………………………………………………………….. snem ……………………………
(kynthei/shynrang) ………………………………………………………………………………………………………..
Relation (if any) ……………………………… address and contact no …………………………………………………
………………………………………. jingiadei bad ka nongpun khun …………………………………………….. jaka
sah bad phone number …………………………………………………………………………………………………….
Signature of the person attesting thumb impression …………………………………… date …………………... jingsoi
u nongsakhi ia kane ka jing shonti ………………………………………………… tarik …………………..................
DECLARATION OF DOCTOR/PERSON CONDUCTING
PRE NATAL DIAGNOSTIC PROCEDURE/TEST
I, __________________________________ (name of the person conducting ultrasonography/image scanning) declare
that while conducting ultrasonography/image scanning on Ms./Mr. __________________ ______________________
(name of the pregnant woman or the person undergoing pre natal diagnostic procedure/test), I have neither detected
nor disclosed the sex of her fetus to anybody in any manner.
Date: Signature: ________________________________________
_______________________________________________
Name in Capitals, Registration Number with Seal of the
Gynaecologist/Radiologist/Registered Medical Practitioner
4
Conducting Diagnostic procedure