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8, 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 poricd/ weeks of pregnancy H;story of genetic/medical disease :n the family (specify) Basis of diagnosis: (a) Clinical (b) Bio-Chemical (c) Cyto-genetic (d) Other (e.g. radiological) Indication for prenatal diagnosis* A. Previous child/children with: (i) Chromosomal disorders (ii) Metabolic disorders (iii) Congenital anomaly 28 THE GAZETTE OF INDIA: EXTRAORDINARY [PART II—SEC. 3(i)] 9-