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    Anand Chiney
    This document records information from an ultrasound of a pregnant woman named Mrs. Madhuri Pravin Pethe. She is 29 years old, Hindu, and already has one child who is male. The ultrasound was performed at the Shreevardhan Xray and ultrasound clinic in Nagpur. It was conducted by Dr. Rajendra Prakashey and found the pregnancy to be normal with no abnormalities detected. The results were communicated to Mrs. Pethe on the same day and no termination of the pregnancy was advised. Both Mrs. Pethe and Dr. Prakashey declared that the sex of the fetus was not detected or disclosed during the ultrasound examination.

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    Form F

    Uploaded by

    Anand Chiney
    4K views2 pages
    This document records information from an ultrasound of a pregnant woman named Mrs. Madhuri Pravin Pethe. She is 29 years old, Hindu, and already has one child who is male. The ultrasound was performed at the Shreevardhan Xray and ultrasound clinic in Nagpur. It was conducted by Dr. Rajendra Prakashey and found the pregnancy to be normal with no abnormalities detected. The results were communicated to Mrs. Pethe on the same day and no termination of the pregnancy was advised. Both Mrs. Pethe and Dr. Prakashey declared that the sex of the fetus was not detected or disclosed during the ultrasound examination.

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    This document records information from an ultrasound of a pregnant woman named Mrs. Madhuri Pravin Pethe. She is 29 years old, Hindu, and already has one child who is male. The ultrasound was performed at the Shreevardhan Xray and ultrasound clinic in Nagpur. It was conducted by Dr. Rajendra Prakashey and found the pregnancy to be normal with no abnormalities detected. The results were communicated to Mrs. Pethe on the same day and no termination of the pregnancy was advised. Both Mrs. Pethe and Dr. Prakashey declared that the sex of the fetus was not detected or disclosed during the ultrasound examination.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    4K views2 pages

    Form F

    Uploaded by

    Anand Chiney
    This document records information from an ultrasound of a pregnant woman named Mrs. Madhuri Pravin Pethe. She is 29 years old, Hindu, and already has one child who is male. The ultrasound was performed at the Shreevardhan Xray and ultrasound clinic in Nagpur. It was conducted by Dr. Rajendra Prakashey and found the pregnancy to be normal with no abnormalities detected. The results were communicated to Mrs. Pethe on the same day and no termination of the pregnancy was advised. Both Mrs. Pethe and Dr. Prakashey declared that the sex of the fetus was not detected or disclosed during the ultrasound examination.

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    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.

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