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 and address of genetic Clinic) (Referral not be preserved
           carefully  with case paper)

    6.    Type of sample : Maternal blood/Chorionic villus sample/amniotic fluid/Foetal blood or other foetal
            tissue  (specify)
 

    7.    Specify indication for pre-natal diagnosis

            A.     Previous child/children with :

            (i)     Chromosomal disorders

            (ii)     Metabolic disorders

            (iii)     Malformation(s)

            (iv)     Mental retardation

            (v)     Hereditary haemolytic anaemia

            (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)

      8.    Laboratory tests carried out (give details)

            (i)     Cromosomal studies

            (ii)     Bio-Chemical studies

            (iii)     Molecular studies

    9.    Result of pre-natal diagnosis :

            If abnormal, give details                                             Normal/Abnormal

    10.    Date(s) on which tests carried out

                        The results of the pre-natal diagnostic tests were conveyed to --------------------------------

                        on --------------------

    Date

                                                            Name, Signature and Registration number of the Medical Geneticist