2
3
Registration No.
Patients name and her religion, income& age :
Total: 0
5.
Husbands/Fathers name -
Mr Ashish Tiwari
6
.
7
.
8
9.
10
11.
12
13.
Female : 0
Hospital,
Sankatmochan
Mainde Chowk, Yawatmal
dt : 09/1/13 wk: 12
Road,
EDD: 16/10/13
Not Applicable
Not Applicable
Not Applicable
Ultrasound
NO
NO
NO
NO
NO
NO
NO
1 Abortion
NO
NO
Not applicable
Dr Rajendra Prakashey MMC reg No44552
Non-Invasive
YES
(1)Ultrasound ( specify purposefor which ultrasound is tobe done
During pregnancy) [ List of indications for ultrasonography of pregnant
Women are given in the note below]
Invasive
(ii)Amniocentesis
(iii) Chorionic Villi aspiration
(iv) Foetal biopsy
(v) Cordocentesis
(vi) Any other (specify)
Any complication of procedure please specify
Laboratory tests recommended1[3] --(i) Chromosomal studies
(ii) Biochemical studies
(iii) Molecular studies
(iv) Preimplantation genetic diagnosis
YES
14.
Result of
(a) pre-natal diagnostic procedure (give details)
18.
(b) Ultrasonography
(specify abnormality detected, if any).
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?
19.
Date: 03/04/13
15.
16.
17.
Place : Nagpur
03/04/13
03/04/13
Rashmi Ashish Tiwari on 03/04/13
NO
Dr Rajendra Prakashey.
Name and signature of the person conducting
ultrasonography/image scanning/ Director or owner of
genetic clinic/ ultrasound clinic/imaging centre.