Pre-Cervical Cancer Counselling & Linkage Form

Completed by referring clinicians at SDPs (ART, PMTCT, OPD, etc.)

Visit Date: ____/____/______

Name: ___________________________ MRN: __________ UAN: _____________ Age: _____

CxCa screening counselling offered? □ Yes □ No

CxCa screening counselling accepted? □ Yes □ No
Date accepted: ____/____/______
Have you ever been (previously) screened for CxCa? □ Yes □ No □ Don’t Know
If yes, date screened: ____/_____/_________
Eligibility for screening on this visit
1. Never Screened
2. Screened negative before 2 years
3. Screened positive & Treated with Cryo/ thermocoagulation or LEEP before 1 year
4. Other reasons for eligibility, specify: ____________________
5. Not eligible
If eligible, Cervical Cancer screening service accepted. □ Yes □ No
Person accompanied the client to CxCa Unit /Adherence Counselor
Is client linked to CxCa Screening unit? □ Yes □ No

Date linked to CxCa screening unit: ____/____/______ Signature: _______________

Version: Meskerem 2013