Histopathology Form v 0.01
Patient Demographics
Given Name:
Family Name:
Middle Name:
AMRS ID Number
Gender:
...
Male
Female
Date Of Birth:
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:
*
Procedures Done This Visit
Body Part Where Specimen Was Collected?
*
...
Cervix
Vagina
Vulva
How was specimen collected?
*
...
LEEP
Cervical punch/excisional Biopsy
Endocervical curretage (ECC)
Provide Location Of Specimen
...
Superficial
Deep
Other non-coded
Provide location where biopsy for specimen was done: __O'clock
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 non-coded
Pathological Diagnosis for Vaginal Specimen
...
Normal
Mild vaginal intraepithelial neoplasia (VAIN1)
Moderate vaginal intraepithelial neoplasia (VAIN 2)
Severe vaginal intraepithelial neoplasia (VAIN 3)
Other non-coded
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 non-coded
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
"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
Philip Kipkirui Tonui
Ann Jebet Ngelel
Job Wekesa Wamukaya
Joyce Chepkorir Chessum
Monica Chelimo Rotich
Penina Jerotich Biwott
Peter Gachingi Kamau
Phanice Jepkemoi Tomu
Roselyne Yatich
Roselyne Yatich
Ruth Sego
Yosabia Osebe Monari
Philip Kipkirui Tonui
Enter provider's system-id:
*
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