F - Assist for PNDT

Section A — To be filled for all diagnostic procedures

Mobile no. *

Enter this first — if the patient has been here before, their details fill in automatically.

3. Patient's name *

Age (years) *

Patient's name in Gujarati *

Auto-filled from the English name — please check & correct it for the Gujarati declaration.

4. Total no. of living children with sex of each child *

Male

Female

Total (auto)

5. Relation *

Name *

6. Full postal address of the patient *

Village / City *

Location of patient *

District *

Taluka / Block *

LMP (last menstrual period) *

Fill LMP or weeks of pregnancy (at least one).

Weeks of pregnancy *

Fill weeks or LMP (at least one).

LMP / weeks of pregnancy not known Print these fields blank for hand-filling later.

7. Referred by / Self-referral *

Doctor / Centre name *

Referrer address *

Referrer location *

Referrer district *

Referrer taluka / block *

Fill this before the scan and print the 3 copies. The patient signs. The result is added after the scan using the button below.

9. Doctor performing *

12. Declaration date *

10. Indication(s) for ultrasound *

Pick one. Choose again to add another.

Click after the ultrasound to enter the result and complete the form.

Names, procedure and dates auto-fill from the data above. Use the toggle below only when the patient gives a thumb impression instead of signing.

In case of thumb impression