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.-

Shreevardhan Xray and ultrasound

clinic at Shreevardhan commercial
complex. 7,Wardha Road, Nagpur

2
3

Registration No.
Patients name and her religion, income& age :

40
Mrs. Laxmi Sunil Haswani
Hindu,32yr

Number of children with sex of each child -

Total: 1

5.

Husbands/Fathers name -

Mr. Sunil Haswani

6
.

Full address with Tel. No., if any

Plot no 14/A,Ganapati Nagar,Jalgaon.

Male:1

Female : 0

Ph- 9423492226
7
.

8
9.

10

11.

12
13.

Referred by (full name and address of

Doctor(s)/Genetic Counselling Centre

Dr Ashish Mashankar, Near Gopal

Talkies, Rajapeth, Amravati

Last menstrual period/weeks of pregnancy

dt : 28/10/12 wk: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, 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)
C. Mother/father/sibling has genetic disease
(specify)
D. Other (specify)
Procedures carried out (with name and registration
no. of registered practitioner who performed it

EDD:04/8/12

Not Applicable
Not Applicable
Not Applicable
Ultrasound

NO
NO
NO
NO
NO
NO
NO
NO
NO
NO

For Fetal Reduction

Dr Rajendra Prakashey MMC reg No44552
Non-Invasive
NO
(1)Ultrasound ( specify purposefor which ultrasound is to be done
During pregnancy) [ List of indications for ultrasonography of pregnant
Women are given in the note below]

Invasive
(ii)Amniocentesis
(iii) Chorionic Villi aspiration
(iv) Foetal biopsy
(v) Cordocentesis
(vi) Any other (specify)
Any complication of procedure please specify
Laboratory tests recommended1[3] --(i) Chromosomal studies
(ii) Biochemical studies
(iii) Molecular studies
(iv) Preimplantation genetic diagnosis

YES

1 fetus reduced. 2 fetuses alive and well

NO
NO

14.

Result of
(a) pre-natal diagnostic procedure (give details)

1 fetus reduced. 2 fetuses alive and

well 1/01/2013
NORMAL

18.

(b) Ultrasonography
(specify abnormality detected, if any).
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?

19.

Date on which MTP carried out.-

MTP not done

Date:
Place

Dr Rajendra Prakashey MMC reg No44552

15.
16.
17.

1/01/2013
Nagpur

1/01/2013
1/01/2013
Laxmi Sunil Haswani on 1/01/2013
NO

Name, Signature and Registration number of

the Gynaecologist/radiologist/Director pf the

--------------------------------------------------------------------------------------------------------------------------------------DECLARATION OF PREGNANT WOMAN

I, Mrs. Mrs. Laxmi Sunil Haswani declare that by undergoing ultrasonography /image
scanning etc. I do not want to know the sex of my foetus. 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. Mrs. Laxmi Sunil Haswani 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.