MFM-I
Application for Accreditation as First Fellow in Maternal-Fetal Medicine, HKCOG
I would like to apply for accreditation to be a First Fellow in Maternal-Fetal Medicine.
I.
Personal data
Name (Surname first)
__________________________________________
HKID/Passport Number
__________________________________________
Sex
Date of birth
_____________
Correspondence address
__________________________
__________________________________________
__________________________________________
Phone
II
____________
Fax
____________
E-mail
______________
Medical education and training
Medical school ___________ Basic degree
________
Year
_________
Qualifications:
MRCOG / MRACOG*
Year _______
MHKCOG
Year __________
FHKAM
Year _______
FHKCOG
Year __________
FRCOG / FRACOG*
III.
Year _________
MFM training ____________________________________
Year _________
Others __________________________________________
Year _________
Type of practice: HA / University / Private*
*(delete as appropriate)
endorsed by Council on 11th November 2004
1
IV.
Past Experience of Attachment / Training in Maternal-Fetal Medicine:
Yes / No
If yes, please specify (including dates, location and nature).
V.
Categories of pregnancies with maternal/fetal/perinatal disorders/complications
managed by you, and other related work e.g. Medico-legal consultation, during
one representative year in the past 5 years.
Period from _____________ to _______________
Number
1. Poor obstetric history (recurrent miscarriage/pregnancy loss,
significant perinatal and intrapartum complications) and
demographic high-risk group requiring serial monitoring and/or
prophylactic treatment.
2. Significant family history of hereditary conditions.
3. Conception by assisted reproduction technology and related
complications.
4. Multiple pregnancy and related complications.
5. Significant fetal congenital anomalies requiring serial
assessment and/or therapeutic intervention.
6. De novo fetal complications (hydrops fetalis, cardiac
arrhythmia etc) requiring monitoring and/or intervention.
7. Fetal growth restriction of early onset (<32 weeks) or extreme
growth restriction (<3rd percentile).
8. Persistently abnormal fetal lie at term.
9. Significant uterine abnormalities including fibroids causing
malpresentation, previous uterine surgery and repair, cervical
and vaginal problems).
10. Preterm labour presenting before 32 weeks from all causes
(including PROM).
endorsed by Council on 11th November 2004
2
11. Antepartum haemorrhage requiring serial monitoring, and/or
intervention before 32 weeks.
12. Hypertensive disorders requiring medical treatment (all
categories).
13. Diabetes complicating pregnancy (pre-gestational and
gestational).
14. Other endocrine disorders requiring treatment during
pregnancy.
15. Respiratory, gastrointestinal and neurological conditions
requiring medical treatment during pregnancy.
16. Hepatobiliary and pancreatic conditions (including active
hepatitis but not asymptomatic HBsAg carrier, fatty liver,
gall stones, and pancreatitis).
17. Autoimmune conditions, antiphospholid syndrome,
thromboembolic and haematological (excluding anaemia due
to iron deficiency and thalassaemia traits) complications.
18. Cardiac conditions requiring treatment.
19. Chronic renal diseases requiring serial assessment and/or
treatment.
20. Significant psychological/psychiatric complications requiring
consultation/treatment.
21. Maternal malignancies.
22. Maternal trauma requiring hospitalization and/or surgery.
23. Postpartum complications requiring resuscitation under
intensive care and/or surgical treatment.
24. Others (please elaborate)
endorsed by Council on 11th November 2004
3
VI.
Number of the following maternal/fetal procedures performed under one principal
diagnosis in one representative year over the past 5 years
Preterm delivery < 33 weeks
Preterm caesarean section < 33 weeks
Caesarean section for major placenta praevia and accreta
Caesarean section for transverse/oblique lie
External cephalic version/internal podalic version
Repeat caesarean section after two or more previous sections
Classical caesarean section
Repair of uterine laceration or rupture
Caesarean hysterectomy
Cervical cerclage
Repair of third and fourth degree vaginal tear
Repair of cervical tear
Evacuation of vulvovaginal haematoma
Ultrasound scanning at level 3, Biophysical profile and/or
Doppler Studies
Diagnostic amniocentesis
Chorionic villus sampling
Other invasive fetal diagnostic procedures such as
embryoscopy, fetal blood sampling, fetal biopsy etc.
Fetal therapy procedures
endorsed by Council on 11th November 2004
4
MFM-II
Application for Position of First Fellow in Maternal-Fetal Medicine, HKCOG
List of patients seen:
Period from
ID No.*
/
/
to
/
/
Diagnosis/Condition
*Include character and first 5 digits of ID. No. only.
Name
&
signature:
Name and Signature of applicant
Certification Unit Head/Hospital administrator
Date:
endorsed by Council on 11th November 2004
5
MFM-III
Application for Position of First Fellow in Maternal-Fetal Medicine, HKCOG
Summary of Clinical Experience in Management Skills
Period from
ID No.*
/
/
to
/
/
Diagnosis/Procedure/Management
*Include character and first 5 digits of ID. No. only.
“Management” includes diagnostic and treatment procedures of all modalities, counseling,
and supervision of other doctors in special procedures.
Name
&
signature:
Name and Signature of applicant
endorsed by Council on 11th November 2004
Certification Unit Head/Hospital administrator
6
Date:
endorsed by Council on 11th November 2004
7
MFM-IV
Application for Position of First Fellow in Maternal-Fetal Medicine, HKCOG
Maternal-Fetal Medicine related CME activities in the past 5 years (please use
additional sheets if necessary)
Activities
CME points
Attending conferences/lectures/talks
Delivering lectures/talks
Publications
Quality assurance
Others
Note: Applicants may be invited to submit the following documents to substantiate the
application.
1.
2.
3.
4.
Individual case records of patients managed by you.
CME attendance certificate.
Publications.
Announcement of lectures/CME activities with you as the speaker.
Name of applicant
Signature
Date
Use additional sheets if necessary.
endorsed by Council on 11th November 2004
8