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 and 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) Basis of diagnosis :

            (a)     Clinical

            (b)     Bio-Chemical

            (c)     Cyto-genetic

            (d)     Other (e.g. radiological-specify)

    8.    Indication for pre-natal diagnosis

            (A)     Previous child/children with :

                    (i)     Chromosomal disorders

                    (ii)     Metabolic disorders

                    (iii)     Congenital anomaly

                    (iv)     Mental ratardation

                    (v)     Haemoglobinopathy

                    (vi)     Sex linked disorder

                    (vii)     Any other (specify)

            (B)     Advanced maternal age (-35 years)

            (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.

             (i)     Ultrasound

            (ii)     Aminiocentesis

            (iii)     Chorionic Villi aspiration

            (iv)     Foetal biopsy

            (v)     Cordocentesis

            (vi)     Any other (specify)

    10.    Any complication of procedure-please specify

    11.    Laboratory tests recommended*

            (i)     Chromosmal studies

            (ii)     Bio-Chemical studies

            (iii)     Molecular studies

    12.    Result of pre-natal diagnostic procedure and specify abnormality 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

              Place                                                Gynaecologist/Radiologist/Registered Medical

                                                                       Practitioner