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.-

Registration No.

Patients name and her religion, income& age :

Shreevardhan Xray and ultrasound

clinic at Shreevardhan commercial
complex.
7,Wardha Road, Nagpur
40
Mrs. Madhuri Pravin Pethe

Number of children with sex of each child -

Hindu, 29yr
Total: 1 Male: 1

5.
6.

Husbands/Fathers name Full address with Tel. No., if any

7
.

Referred by (full name and address of

Doctor(s)/Genetic Counseling Centre

8.

Last menstrual period/weeks of pregnancy

9.

History of genetic/medical disease in the family

(specify)
Basis
of diagnosis:
(a) Clinical
(b) Bio-chemical

10

(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)

11.

12
13.

D. Other (specify)
Procedures carried out (with name and registration
no. of registered practitioner who performed it

Mr. Pravin Pethe

Plot no- 49, Adiwasi Layout,
Chinchbhavan, Wardha Road, Nagpur
Ph- 9890252506
Dr Pramila Badki, Mamta Hospital,
Laxmi Vihar Apartments, Near Hotel
Airport
Centre
Point,
Somalwada,
Wardha road, Nagpur
Dt : Not Known Wks:
NO
Not Applicable
Not Applicable
Not Applicable
Ultrasound

NO
NO
NO
NO
NO
NO
NO
1 Abortion
NO
Fetal age, Placenta, liquor, Doppler
Study
Dr Rajendra Prakashey MMC reg No44552
YES

Non-Invasive
(1)Ultrasound ( specify purpose for which ultrasound is to be done
During pregnancy) [ List of indications for ultrasonography of pregnant
Women are given in the note below]
Invasive
NO
(ii)Amniocentesis
(iii) Chorionic Villi aspiration
(iv) Foetal biopsy
(v) Cordocentesis
(vi) Any other (specify)
Any complication of procedure please specify
NO
Laboratory tests recommended1[3] --NO

(iii) Molecular studies

(iv) Preimplantation genetic diagnosis

Female : 0

14.

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

USG
NORMAL

(Specify abnormality detected, if any).

15.
16.
17.
18.
19.

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?
Date on which MTP carried out.-

Date:
Place

11/04/2013

11/04/2013
Not applicable
Mrs. Madhuri Pravin Pethe on
11/04/2013
NO
MTP not done

Dr Rajendra Prakashey MMC reg No44552

Nagpur

Name, Signature and Registration number of

the Gynaecologist/radiologist/Director pf the

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

I, Mrs. Madhuri Pravin Pethe, declare that by undergoing ultrasonography /image
scanning etc. I do not want to know the sex of my fetus. 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 . Madhuri Pravin Pethe, 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.