Cervical Cancer Screening - Visual Examination Reporting Form

Visual Examination Reporting Form

Saloney Nazeer
Geneva WHO Collaborating Centre in Education and Research in Human Reproduction

PATIENT'S PROFILE
Name	Last:	First:	Middle:
Age:
Address:
ORIGINATING CENTRE:
Date:
Address:
Date of marriage:	No. of childrens:
Menstrual cycles:	REGULAR:	IRREGULAR:
Intermenstrual bleeding:	YES:	NO:
Contact bleeding:	YES:	NO:
Pregnant:	YES:	NO:
Last menstrual period:
Contraceptives:	YES (specify):	NO:
Cytological examination:	YES:	NO:
If yes,	Date:	Result:
HUSBAND'S MEDICAL HISTORY (If ever been treated for STD):
PER-SPECULUM EXAMINATION OF THE CERVIX:
Discharge:	Normal:
	Bloody:
	Dirty/greenish:
	Foul smelling:
	White/cheesy:
Appearance of cervix:	Normal:
	Abnormal:	hypertrophy
		redness/congestion
		irregular surface
		distortion
		erosion (does not bleed on touch)
		polyp/growth (with smooth surface)
		Nabothian follicles
		prolaspsed uterus
	Suspicious of malignancy:	erosion (friable or bleeds on touch)
		growth (friable/fungating/irregular)
		non-specific appearance
PLAN OF ACTION
Swab taken for culture:	YES:	NO:
Smear taken:	YES:	NO:
Advice given:	Rescreen after one year
	Referred to PHC
	Referred to oncology centre
			(SIGNATURE)

Edited by Aldo Campana,