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 and address of Doctor(s) with registration No.(s) (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)     Cytogenetic

            (d)     Other (e.g. radiological)

    8.     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 disorder

            (vii)     Any other (specify)

            B.     Advanced maternal age (--35 years)

            C.     Mother/Father/sibling has genetic disease (specify)

            D.     Others (specify)

    9.    Procedure advised*

            (i)     Ultrasound

            (ii)     Amniocentesis

            (iii)     Chorionicvilli biopsy

            (iv)    Foetoscopy

            (v)     Foetal skin or organ biopsy

            (vi)     Cordocentesis

            (vii)     Any other (specify)

    10.    Laboratory tests to be carried out

            (i)     Chromosomal studies

            (ii)     Bio-Chemical studies

            (iii)     Molecular studies

    11.    Result of pre-natal diagnosis :

             If abnormal give details.                                     Normal / Abnormal

    12.    Was MTP advised ?

    13.    Name and address of Genetic Clinic* to which patient referred.

    14.    Dates of commencement and completion of genetic counselling.

                                                                                                        Name, Signature and Registration No.

                                                                                             of the Medical Geneticist/Gynaecologist/paediatrician.

Date :

____________________________________________________________________________

Strike out whichever is not applicable or necessary.