Form 274a - Take Charge! Breast And Cervical Cancer Screening Form (Page 2 of 2) in pdf

Take Charge! Breast and Cervical Cancer Screening Form

ODH Form No.274A

Chart ID #________________________________

Part 6: CERVICAL CANCER SCREENING INFORMATION

Previous Pap test?  Yes

 No

 Unknown

Facility:_______________________________________ Date: _____/_____/________

Hysterectomy?  Yes

 No

Date: _____/_____/________ Cervical Cancer? :  Yes

 No

Date: _____/_____/________

Past Abnormal Pap?

 Yes

 No Year: ________ Type: ________ Treatment Method: _______________________________

Part 7A: INDICATION FOR PAP TEST

 Breast record only, cervical services not done

 Pap test not done patient proceeded directly for diagnostic workup

 Diagnostic referral

or HPV testing

 Patient under surveillance for previous abnormal test

 Unknown

 Routine Pap test

Part 7B: PELVIC INFORMATION

Part 7C: PAP TEST

Type of exam:  Pelvic  Visual vaginal/perineal

Facility name: _____________________________________

Date of exam: ______/______/_______

Date Pap test performed: _____/_____/________

Paid by Take Charge! Program?  Yes

 No

 Unknown

Specimen type for Pap test:

 Conventional Smear

Results:

 Abnormal (Not Suspicious for cervical cancer)

 Liquid based  Other  Unknown

 Abnormal (Suspicious for cervical cancer)

Paid by Take Charge! Program?

 Yes

 No

 Unknown

 Abnormal Pelvic

Date results received: _____/_____/______

 Normal

Date client notified: _____/_____/______

 Not done – Normal PE in past 12 months (attach

Specimen adequacy:  Satisfactory  Unsatisfactory

 Unknown

records)

 Not done – Other/unknown reason

Results of Pap test:

 Not indicated/Not needed

 Adenocarcinoma

 AGUS

 Refused

 AGC (Atypical glandular cells)

 ASC-H

Clinical Comments:

 AIS (Endocervical adenocarcinoma in situ)

 ASC-US

Please note: Handwritten notes are not entered

 Squamous cell carcinoma

 HSIL

 LSIL includes HPV, mild dysplasia, CIN1

Result Pending



 Negative for intraepithelial lesion/malignancy

 Other

 Result unknown (presumed abnormal, Pap from non - Take

Charge! facility)

HPV Performed?  Yes

 No

Date of HPV: ____/____/_______

Paid by Take Charge! Program?  Yes

 No

HPV test result:  Positive

 Negative

 Unknown

Cervical Work-up Planned:

 Yes (needed or planned) (mark type of work-up below)

 4 month short term follow up

 Colposcopy w/o biopsy

 Hysterectomy

 Pelvic ultrasound

 6 month follow up

 Obtain definitive treatment

 HPV test

 Pap in 1 yr

 Cold Knife Cone (CKC)

 Endocervical Curettage (ECC)

 LEEP

 Pap in 2 yrs

 Colposcopy with biopsy

 Gynecologic consult

 Other biopsy

 Pap in 5 yrs

 No (not needed) - Follow routine screening

 Repeat Pap test immediately

Part 8: Tobacco Use Information

Have you smoked at least 100 cigarettes in your entire life (5 packs=100 cigarettes)?  Yes

 No  Don’t know/Not sure  Refused

Do you now smoke cigarettes?

 Every day  Some days

 Not at all

 Don’t know/Not sure  Refused

Do you currently use any other type of tobacco such

as cigars, pipes, or smokeless tobacco?

 Every day  Some days

 Not at all

 Don’t know/Not sure  Refused

Do you currently use e-cigarettes or any other type

 Every day  Some days

 Not at all

 Don’t know/Not sure  Refused

of vapor products?

Do you live with anyone who uses tobacco?  Yes  No

Was a fax referral for Quitline (Tobacco cessation) offered to the patient?  Yes

 No

If no, why not? _______________________

Was the fax referral accepted by the patient?  Yes

 No

If no, why not? ___________________________________

Examiner’s Signature:

Date:

Form 2 of 2

ODH Form No. 274A

Revised June 2014

Form 274a - Take Charge! Breast And Cervical Cancer Screening Form Page 2

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