Cervix

1. Screening

Appointment no:

Pt name:

Mob no:

Complaints:(instead of symptoms)
1.watery discharge
2.AUB
3.Post coital bleeding
4.pain abdomen
5.others (writing option)
Cervix :

1.healthy
2.unhealthy
3.any growth
4.others(writing option)
VIA:
POSITIVE
NEGATIVE
Date:
CALENDER OF NEXT 30 YRS
Follow up date(include
calender)

PAP'S Smear cytology :

POSITIVE
NEGATIVE
Date:

CALENDER OF NEXT 30 YRS

Follow up date:(include
calender)
CALENDER OF NEXT 30 YRS
LBC:
POSITIVE
NEGATIVE
Date:
CALENDER OF NEXT 30 YRS
Follow up date:calender

CALENDER OF NEXT 30 YRS

HPV DNA:

Date:
CALENDER OF NEXT 30 YRS
Follow up date(include
calender)
POSITIVE
NEGATIVE

Date:
CALENDER OF NEXT 30 YRS
Follow up date:
CALENDER OF NEXT 30 YRS
COLPOSCOPY:
1.NORMAL
2.SUSPICIOUS
3.ABNORMAL
4.BIOPSY TAKEN
CIN I:
TREATMENT
COLD
LEEP
Date:

CALENDER OF NEXT 30 YRS

Follow up date:calender
CALENDER OF NEXT 30 YRS
CIN II:
TREATMENT
COLD
LEEP
CONE BIOPSY
Date:
CALENDER OF NEXT 30 YRS
CIN III:
TREATMENT
COLD
LEEP
CONE BIOPSY
Date:

CALENDER OF NEXT 30 YRS

Follow up date:calender

CALENDER OF NEXT 30 YRS

HISTOPATHOLOGY:
CIN I
CIN II
CINIII
MICRO INVASIVE
INVASIVE CARCINOMA
CA CERVIX: STAGING :
writing option

TREATMENT:
Squamous cell ca
adenocarcinoma
Others.writing option

TREATMENT:
RADICAL SURGERY:
CALENDER OF NEXT 30 YRS
RADIOTHERAPY:
CALENDER OF NEXT 30 YRS
ADJUVANT:

CALENDER OF NEXT 30 YRS

Follow up date:

CALENDER OF NEXT 10 YRS

save