TEST REQUISITION FORM

TRIPLE/ DOUBLE/QUADRUPLE MARKER PRENATAL SCREENING TESTS (SRL 1267 / 1268 / 1275)
For Patient with an increased risk towards Fetal Down Syndrome (trisomy 21) Neural tube defect (ONTDs)
& Edward syndrome ( Trisomy 18) risk assessment through Prenatal Interpretative software.

Phone ____________ Fax ______________

Test Requested : Triple Marker Double Marker

Quadruple Marker

Patient's Weight Kgs Lbs

Maternal Race: ASIAN CAUCASIAN AFRICAN OTHER ________________

Patient's date of birth ___/___/___ Collection Date ___/___/___

LMP Date ___/___/___

Initial Screening Sample Repeat test Reported date ___/___/___

Present Pregnancy :Singleton Twin

The risk assessment can not be carried out for pregnancies with more than two fetuses.

Maternal History

Smoking Yes No
Previos History of Down's Syndrome Yes No
Previous History of Neural Tube Defect (NTD) Yes No
Insulin dependent diabetes Yes No
Bleeding or spotting in the last two weeks Yes No
IVF Pregnancy Yes No
History of Previous Pregnancies :…………………

Photocopy of the Ultrasound Report as per following details is mandatory.

Latest Ultrasound Report

Date of ultrasound. ___/___/___

CRL measurement (minimum : 38 mm, maximum : 84 mm)……………………

Nuchal Translucency thickness in mm……………………

BPD measurement (minimum : 26 mm, maximum : 52 mm)……………………

Average Gestational Age on the day of USG……………………

Measured by ( Name of the Sonologist): …………………………

Note : This form has to be completely filled for the risk assessment report.
The First / Second trimester risk assessments at SRL can be carried out only between 8th to 14th and 14th to 22nd week of gestation
respectively.
HFQC011/02012013