Papsmear 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:
*
Observation Details
First day of your last menstrual period (LMP)
*
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
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
Prior PAP results
Normal
Atypical squamous cells of undetermined significance
Atypical glandular cells of undetermined significance
Low grade squamous intraepithelial lesion
High grade squamous intraepithelial lesion
Squamous cell carcinoma
Adenocarcinoma
Do not know
Date of most recent PAP result
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
Philip Kipkirui Tonui
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:
*
Comments