Dysplasia 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
Visit Type:
*
...
New Visit
Revisit
Review of pathology results
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
Number of previous pregnancies
*
If client has never been pregnant, enter '0'.
Number of previous deliveries
*
The number of children a woman has delivered?
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
HIV status
...
Negative
Positive
Unknown
Most Recent Observations
Latest CD4 count
Date of latest CD4 count
History of Dysplasia
...
Yes
No
Prior Visual Inspection with Acetic Acid (VIA)
...
Positive
Negative
Do not know
Not Applicable
Date of most recent VIA result
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
Prior colposcopy results
Normal
Cervical intraepithelial neoplasia grade 1
Cervical intraepithelial neoplasia grade 2
Cervical intraepithelial neoplasia grade 3
Cervical cancer
Not Applicable
Do not know
Date of most recent colposcopy result
Other biopsy results
Date of most recent biopsy result
Past treatment of dysplasia
A question set to ask what past treatments the patient has received for Dysplasia, the date of that treatment, and the pathology of the treatment.
Loop electrosurgical excision procedure
Hysterectomy
Cryotherapy
Other
None
Not Applicable
Pathological diagnosis for cervical specimen
The histo-pathological findings regarding dysplasia as found by the most recent treatment for the condition.
Normal
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
Visual cervical exam findings
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
Normal
Vaginal intraepithelial neoplasia grade 1
Vaginal intraepithelial neoplasia grade 2
Vaginal intraepithelial neoplasia grade 3
Other
Visual vulval exam findings
Normal
Condyloma or vulvar intraepithelial neoplasia grade 1
Vulvar intraepithelial neoplasia grade 2
Vulvar intraepithelial neoplasia grade 3
Other
Is Provider Satisfied With Quality of Colposcopy Done During Today's Visit?
...
Yes
No, entire squamocolumnar junction (SCJ)not seen
Colposcopy not done today
Extent of Visualized Lesion
...
<50% of cervix
>50% of cervix
Extends into canal
Findings:
...
Normal
Punctuation
Acetowhite lesion
Mosaicism
Atypical Vessels
Internal borders (variegated)
Other non-coded
Do not know
Procedures Done
Procedure done this visit
...
Biopsies
Endocervical curettage (ECC)
Cryotherapy
Loop Electrosurgical Excision Procedure (LEEP)
None
Provide Location of specimen
...
Superficial
Deep
Other
Provide location where biopsy for specimen was done: __O'clock
Number of speciment collected
Management Plan
*
...
VIA 6 Months follow up
Routine VIA in 1-year
Routine VIA in 3-years
Referral for Colposcopy
Referral to Gynae-Oncology
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
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
Provider Name:
Enter provider's system-id:
*
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
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