Life Quest Clinical Lab

Maharajgunj-03, Panipokhari Kathamndu

01-4002747 lifequestclinicallab@gmail.com

MATERNAL SERUM SCREEN REQUISITION FORM

Please tick requested test

DOUBLE MARKER TRIPLE MARKER QUADRUPLE MARKER

Patient’s Name : Referred By :

Patient’s SID : Mobile No :

Information
Patient

DOB(DD/MM/YY) : Email:

Weight .............................. kg LMP(DD/MM/YY): Sample Type

Height ............................... ft Sample Collection Date: Initial Repeat
Para:………Gravida:……… H/O Diabetes:………(Y/N) Smoker:………(Y/N)
Blood Group:……………………………

Medication:……………………(Y/N). If Yes please specify....................................................................................

Gestation : SINGLETON………(Y/N)
MULTIPLE………If Yes: DICHORIONIC………MONOCHORIONIC………

Type of Pregnancy: NORMAL………(Y/N) IVF………(Y/N)

If IVF Yes: OWN EGGS………(Y/N) DONOR EGGS………(Y/N)
DOB of Donor: (DD/MM/YY):……………….
Transfer Date:………………………Harvest Date:…………Fertilization Date:……………Days in
vitro:…….Days
Previous pregnancy with chromosomal abnormality:
History Case

YES……… NO………
IfYes: TRISOMY21………(Y/N) TRISOMY13/18……(Y/N)NTD………(Y/N)

Note: In women with previous positive screen result alternative prenatal testing i.e., Chorionic villus
sampling/amniocentesis is advisable instead of maternal serum screen.
Date of Ultrasound (DD/MM/YY) ……………………………………………….
Gestational Age as per scan……………………………………….Weeks days
Ultrasound Information

EDD:

(PHOTOCOPY OF THE USG REPORT TO BE ATTACHED)

USG DETAILS TO BE FILLED SPECIFICALLY
CRL No ………(mm) Biparietal Diameter (BPD) : ………(mm)

Applicable Time of Screen Information Recorded By:

Double Marker : 9 Weeks -13 Weeks 6 Days Name:
Quadruple Marker: 14 Week-21 Weeks 6 Days Designation:
Mobile No:
Signature: