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    Form F Reduction Follow Up

    Uploaded by

    Anand Chiney
    (1) Mrs. Sultana Parvez Sheikh, a 40-year old Muslim woman, was referred for an ultrasound by Dr. Shilpi Sud at 11 weeks of pregnancy. (2) The ultrasound conducted by Dr. Rajendra Prakashey found two non-viable fetuses. (3) No abnormalities were detected in the ultrasound and medical termination of pregnancy was not advised or conducted.

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    © All Rights Reserved
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    Form F Reduction Follow Up

    Uploaded by

    Anand Chiney
    346 views2 pages
    (1) Mrs. Sultana Parvez Sheikh, a 40-year old Muslim woman, was referred for an ultrasound by Dr. Shilpi Sud at 11 weeks of pregnancy. (2) The ultrasound conducted by Dr. Rajendra Prakashey found two non-viable fetuses. (3) No abnormalities were detected in the ultrasound and medical termination of pregnancy was not advised or conducted.

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    Form R FRU

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    (1) Mrs. Sultana Parvez Sheikh, a 40-year old Muslim woman, was referred for an ultrasound by Dr. Shilpi Sud at 11 weeks of pregnancy. (2) The ultrasound conducted by Dr. Rajendra Prakashey found two non-viable fetuses. (3) No abnormalities were detected in the ultrasound and medical termination of pregnancy was not advised or conducted.

    Copyright:

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

    Form F Reduction Follow Up

    Uploaded by

    Anand Chiney
    (1) Mrs. Sultana Parvez Sheikh, a 40-year old Muslim woman, was referred for an ultrasound by Dr. Shilpi Sud at 11 weeks of pregnancy. (2) The ultrasound conducted by Dr. Rajendra Prakashey found two non-viable fetuses. (3) No abnormalities were detected in the ultrasound and medical termination of pregnancy was not advised or conducted.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    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. Sultana Parvez Sheikh

    Number of children with sex of each child -

    Total: 0

    5.
    6.

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

    Mr. Parvez Sheikh


    Mominpura, Gardline, Near Chand
    Hotel, Boriyapura Idgah, Nagpur
    Ph-9370533788

    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

    Dr Shilpi Sud, Vasantsheela Towers, 4th


    Floor, Lokmatbhavan opp. Wardha
    road, Nagpur
    Dt : 03/11/12 wk: 11
    EDD:
    10/08/13
    NO

    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

    Male: 0

    Not Applicable
    Not Applicable
    Not Applicable
    Ultrasound

    NO
    NO
    Yes- 1 Child Died
    NO
    NO
    NO
    NO
    NO
    NO
    Fetal well being and to confirm viability
    of reduced
    Dr
    Rajendrafetus.
    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.

    15.
    16.
    17.
    18.
    19.

    Result of
    (a) pre-natal diagnostic procedure (give details)
    (b) Ultrasonography
    (Specify abnormality detected, if any).

    USG
    NORMAL .{Two reduced fetuses which
    are not live}

    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.-

    24/01/13
    Not applicable
    Mrs. Sultana Parvez Sheikh on
    24/01/13
    NO
    MTP not done

    Date:
    Place

    24/01/13

    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. Sultana Parvez Sheikh, 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 . Sultana Parvez Sheikh, 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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