Colposcopy Pathology Requisition Form
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COLPOSCOPY PATHOLOGY REQUISITION
* REQUIRED INFORMATION
PROVINCE
PERSONAL HEALTH NUMBER (PHN)
REGIONAL HEALTH
* PHYSICIAN TO ACT ON RESULTS:
RECORD NUMBER
___ __ ___ ___ ___ --- ___ ___ ___ ___
Physician Last Name /
Full First Name:
PATIENT LAST NAME
FULL FIRST NAME
MIDDLE NAME
5 Digit Client #:
P
A
T
E I
N
T
A
D
D
R
E
S
S
C
T I
, Y
P
R
O
V
N I
C
E
P
O
S
T
A
L
C
O
D
E
Alpha Suffix Provider #:
CHART NUMBER
GENDER
DATE OF BIRTH
PATIENT PHONE NUMBER
__ __ __ __ / __ __ / __ __
( __ __ __ ) __ __ __ - __ __ __ __
Y Y Y Y
M
M
D D
* TISSUE REMOVED BY:
SAME NAME / LOCATION AS ABOVE
* CURRENT SPECIMEN TAKEN:
FOR LAB USE ONLY - ACCESSION NUMBER
Date: __ __ __ __ / __ __ / __ __
______________________ _______________________ _____________________
Y Y Y Y
M M
D D
Last Name
Full First Name
Location (Office Address)
Time: __ __ : __ __
ADDITIONAL COPIES TO:
H H
M M
1) ______________________ _______________________ ____________________
Last Name
Full First Name
Location (Office Address)
2) ______________________ _______________________ ____________________
Last Name
Full First Name
Location (Office Address)
GYNECOLOGY HISTORY
PRIOR TREATMENT
FIRST COLPOSCOPY VISIT
__ __ __ __ / __ __ / __ __
PREVIOUS PAP RESULT: _______________________________________
YES
NO
Y Y Y
Y
M M
D D
Cryotherapy
__ __ __ __ / __ __ / __ __
LNMP:
Cycle: Every ___________ days
COLPOSCOPIC IMPRESSION
Y
Y
Y
Y
M
M
D
D
Chemotherapy
Hysterectomy (No Cervix)
Post Partum ________ weeks
Laser
LEEP
NEGATIVE
Immunocompromised
Breast feeding
XRT
Cone
HPV / LSIL
IUD
Menopausal
Other _______________
HSIL
Pregnant _________ weeks
OCP
HRT
* Each specimen container must be labelled with the patient’s full first and last name and the exact specimen site.
LAB USE ONLY
BIOPSY
Punch
Cone
Leep
GROSS DESCRIPTION:
Biopsy consists of fragments measuring:
mm greatest
Location: _____ o’clock
Cervix
Vagina
Vulva
Other: __________
LAB USE ONLY
BIOPSY
Punch
Cone
GROSS DESCRIPTION:
Biopsy consists of fragments measuring:
mm greatest
Location: _____ o’clock
Cervix
Vagina
Vulva
Other: __________
LAB USE ONLY
BIOPSY
Punch
Cone
GROSS DESCRIPTION:
Biopsy consists of fragments measuring:
mm greatest
Location: _____ o’clock
Cervix
Vagina
Vulva
Other: __________
LAB USE ONLY
BIOPSY
Punch
Cone
GROSS DESCRIPTION:
Biopsy consists of fragments measuring:
mm greatest
Location: _____ o’clock
Cervix
Vagina
Vulva
Other: __________
LAB USE ONLY
CURETTINGS
BIOPSY
GROSS DESCRIPTION:
Endocervix
Endometrium
Biopsy consists of fragments measuring:
mm greatest
LAB USE ONLY
CURETTINGS
BIOPSY
GROSS DESCRIPTION:
Endocervix
Endometrium
Biopsy consists of fragments measuring:
mm greatest
Laboratory Information Centre: 403-770-3600
CLS Form #REQ9042COL
20140124
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