Visual Examination Reporting Form
Saloney Nazeer
WHO Collaborating Centre in Education and Research in Human Reproduction
| PATIENT'S PROFILE | ||
| Name | Last: | First: |
| Age: | ||
| Address: | ||
| ORIGINATING CENTRE: | ||
| Date: | ||
| Address: | ||
| Date of marriage: | No. of childrens: | |
| Menstrual cycles: | REGULAR: | IRREGULAR: |
| Intermenstrual bleeding: | YES: | NO: |
| Contact bleeding: | YES: | NO: |
| Pregnant: | YES: | NO: |
| Last menstrual period: | ||
| Contraceptives: | YES (specify): | NO: |
| Cytological examination: | YES: | NO: |
| If yes, | Date: | Result: |
| HUSBAND'S MEDICAL HISTORY (If ever been treated for STD): | ||
| PER-SPECULUM EXAMINATION OF THE CERVIX: | ||
| Discharge: | Normal: | |
| Bloody: | ||
| Dirty/greenish: | ||
| Foul smelling: | ||
| White/cheesy: | ||
| Appearance of cervix: | Normal: | |
| Abnormal: | hypertrophy | |
| redness/congestion | ||
| irregular surface | ||
| distortion | ||
| erosion (does not bleed on touch) | ||
| polyp/growth (with smooth surface) | ||
| Nabothian follicles | ||
| prolaspsed uterus | ||
| Suspicious of malignancy: | erosion (friable or bleeds on touch) | |
| growth (friable/fungating/irregular) | ||
| non-specific appearance | ||
| PLAN OF ACTION | ||
| Swab taken for culture: | YES: | NO: |
| Smear taken: | YES: | NO: |
| Advice given: | Rescreen after one year | |
| Referred to PHC | ||
| Referred to oncology centre | ||