Metropolis Healthcare Ltd

MATERNAL SCREEN REQUEST FORM

Double Marker Triple Marker Quadruple Marker

(All information is mandatory)

Name of the Lady: ………………………………… Sample Collection Date: ……/……/……….

Doctor’s Name & Number: ………………………… Race: Asian Caucasian African

D.O.B.: ....../............/..………… Others

LMP Date: ……/……/……….. Smoking: Yes No

Weight: ………………Kg. Gestation: Single Double

USG Date: ……/………/………… Gestational Age: ……………………….

Average Gestational age on the day of USG …..Weeks ……. Days

Insulin Dependent Diabetes Mellitus

Family History of Neural Tube Defects: YES NO

Family History of Down’s syndrome: YES NO

Previous relevant Antenatal History: ……………………………………………………………………….

IVF: Yes No IVF/IUI Date: ……/…………/………

If Yes: Own Egg Donor Egg

If Yes: (Provide D.O.B. of Donor): ……/…………/………..

BPD mm: ……………

For Double Marker Test, please provide following additional information:

CRL mm: …… NT (Nuchal Translucency) mm: ……

Contact No.: ………………………. Signature: ……………………………

(Pregnant Lady) (Pregnant Lady)

*Xerox Copy of last USG should be attached.

*Test not valid for Pregnancy with 3 or more fetuses.