Form For Maintenance Of Records By The Genetic Counselling printable pdf download

Form For Maintenance Of Records By The Genetic Counselling

FORM D

[See rule 9(2)]

FORM FOR MAINTENANCE OF RECORDS BY THE GENETIC COUNSELLING

CENTRE

Name and address of Genetic Counselling centre.

Registration No.

Patient’s name

Age

Husband’s/Father’s name

Full address with Tel. No., if any

Referred by (Full name and address of Doctor(s) with

registration No.(s) (Referral note to be preserved

carefully with case papers)

Last menstrual period/weeks of pregnancy

History of genetic/medical disease in the family

(specify)

Basis of diagnosis:

(a) Clinical

(b) Bio-chemical

(d)Other (e.g.radiological, ulrasonography)

10.

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 or above)

C. Mother/father/sibling having genetic disease (specify)

D. Others (specify)

Form For Maintenance Of Records By The Genetic Counselling