CCSP VIA Form v 0.01
Demographics
AMRS ID Number:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Encounter Details
Name of Dispensary:
*
Screening Site:
*
...
AMPATH-MTRH
Busia
Chulaimbo
Iten
Kitale
Mosoriot Health Centre
Port Victoria
Teso District Hospital
Turbo Health Centre
Webuye
Encounter Date:
*
What is the current visit type?
*
...
New Visit
Revisit
How are your menstrual periods?
*
Screener to select one best option.
...
Normal
Abnormal periods
Completely absent
Pre-menopausal
Menopausal
Post-menopausal
Abnormal bleeding not related to periods
First day of your last period (LMP)
*
Urine pregnancy test
*
Test that determines pregnancy status through measure of hormone content in urine.
...
Negative
Positive
Indeterminate
Poor sample quality
Not Done
Refusal
Do you know why you are not having your period?
*
...
Pregnant
Breastfeeding
Due to age
Do not know
Other
Specify
Number of previous pregnancies
*
If client has never been pregnant, enter '0'.
Number of previous deliveries
*
The number of children a woman has delivered?
HIV status
...
Negative
Positive
Unknown
Latest CD4 count
Date of latest CD4 count
Prior Visual Inspection with Acetic Acid (VIA)
Patient's most recent Visual Inspection with Acetic Acid (VIA) screening.
...
Positive
Negative
Not Applicable
Current family planning method
Condoms
Sterilization / Hysterectomy
Intrauterine device
Diaphragm / Cervical cap
Oral contraceptive pills
Natural family planning
Injectable hormonesa
Implant / Patching
None
Do not know
Select all symptoms that best describe complaints
Pain
Asymptomatic
Hypoglycemia symptoms in past month
Vaginal discharge
Vaginal bleeding
Dysfunctional uterine bleeding
Menorrhagia
Postmenopausal bleeding
Postcoital bleeding
None
Other
Specify
Visual cervical exam findings
Findings on the cervix based on a performed exam.
Normal
Cervical intraepithelial neoplasia grade 1
Cervical intraepithelial neoplasia grade 2
Cervical intraepithelial neoplasia grade 3
Cervical cancer
Positive visual inspection with acetic acid with aceto white area
Positive visual inspection with acetic acid with suspicious lesion
Other
Visual vaginal exam findings
Findings on the vagina based on a performed exam.
Normal
Vaginal lesion suspicious of cancer
Vaginal intraepithelial neoplasia grade 1
Vaginal intraepithelial neoplasia grade 2
Vaginal intraepithelial neoplasia grade 3
Other
Specify
Visual vulval exam findings
Findings on the vulva based on a performed exam.
Normal
Vulva lesion suspicious for cancer
Condyloma or vulvar intraepithelial neoplasia grade 1
Vulvar intraepithelial neoplasia grade 2
Vulvar intraepithelial neoplasia grade 3
Other
Specify
Procedure done this visit
*
...
Biopsies
Endocervical curettage (ECC)
Cryotherapy
Loop Electrosurgical Excision Procedure (LEEP)
Visual Inspection with Acetic Acid(VIA)
None
Provide Location of specimen
...
Superficial
Deep
Other
Provide location where biopsy for specimen was done: __O'clock
Number of specimen collected
Pathological diagnosis for cervical specimen
...
Normal
Cervicitis
Cervical squamous metaplasia
Mild cervical intraepithelial neoplasia (CIN 1)
Moderate cervical intraepithelial neoplasia (CIN 2)
Severe cervical intraepithelial neoplasia (CIN 3)
Cervical adenocarcinoma
Cervical squamous cell carcinoma
Other
Pathological diagnosis for vaginal specimen
...
Normal
Mild vaginal intraepithelial neoplasia (VAIN1)
Moderate vaginal intraepithelial neoplasia (VAIN 2)
Severe vaginal intraepithelial neoplasia (VAIN 3)
Moderate cervical intraepithelial neoplasia (CIN 2)
Severe cervical intraepithelial neoplasia (CIN 3)
Other
Pathological diagnosis for vulval specimen
...
Normal
Condyloma / Mild vulva intraepithelial neoplasia (VIN1)
Moderate vulva intraepithelial neoplasia (VIN 2)
Severe vulva intraepithelial neoplasia (VIN 3)
Other
Management Plan
*
...
VIA 3 months follow up
VIA 6 months follow up
Routine VIA in 1-year
Routine VIA in 3-years
Referral for Colposcopy
Referral to Gynae-Oncology
Referral for Cryotherapy
Referral to Clinician
Discharged from Clinic
Other
None
Directive family planning counseling performed
Yes
No
Family planning refills dispensed
Condoms
Sterilization / Hysterectomy
Intrauterine device
Diaphragm / Cervical cap
Oral contraceptive pills
Natural family planning
Injectable hormonesa
Implant / Patching
None
Other
Specify
New family planning method initiated
Condoms
Sterilization / Hysterectomy
Intrauterine device
Diaphragm / Cervical cap
Oral contraceptive pills
Natural family planning
Injectable hormonesa
Implant / Patching
None
Other
Specify
Provider Name:
Daurine Achieng Agumba
Irene Chepkosgei Kurgat
Rose Cheruto Toroitich
Mary Kipkurui Kimosop
Jacqueline Chemom Ndiema
Grace Wanjiru Mwangi
Collette Mabia Palapala
Dorice Erima Wekesa Female
Agnes Kagure Boen
Linet Kerubo Onyancha
Delinah Muchai Tanui
Hellen Mushimbi Indumbwe
Lydia Cherugut Samoei
Ruth Kalunda Nzili
Lucy Cheruto Birgen
Gratiah Nafuna Khaemba
Leonida Chemutai Mengich
Ann Wangoi Maina
Elkanah Omenge Orango
Peter Mukhanadale Istura
Hillary Mabeya
Astrid Christoffersen Deb
Ann Jebet Ngelel
Job Wekesa Wamukaya
Joyce Chepkorir Chessum
Monica Chelimo Rotich
Penina Jerotich Biwott
Peter Gachingi Kamau
Phanice Jepkemoi Tomu
Phyllis Jelagat Bartilol
Roselyne Yatich
Ruth Sego
Yosabia Osebe Monari
Philip Kipkirui Tonui
Enter provider's system-id:
*
Return visit date: