WOMEN S INTERAGENCY HIV STUDY LABORATORY - PELVIC EXAM STUDIES TREATMENT FORM FORM L16
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1 WOMEN S INTERAGENCY HIV STUDY LABORATORY - PELVIC EXAM STUDIES TREATMENT FORM FORM L16 ID LABEL HERE ---> VISIT #: FORM COMPLETED BY: VERSION DATE: 05/01/95 ANY MISSING OR INCOMPLETE TEST RESULTS MUST BE EXPLAINED ON THIS FORM. A1. DATE OF PROCEDURE: / / M D Y A2. FIRST TREATMENT: A3. REPEATED TREATMENT:... 1 (A5) (a)... 2 (A5) a. total # of treatments (not including this one) A4. DATES OF PRIOR TREATMENTS: METHOD OF TREATMENT: / / M D Y / / M D Y / / M D Y Page 1 of 8
2 A5. INDICATION FOR TREATMENT (Circle the most severe lesion for each) a. Cervical None... 1 Exophytic condyloma... 2 LG SIL: HPV... 3 LG SIL: CIN1 (Mild dysplasia)... 4 LG SIL: Unspecified... 5 HG SIL: CIN II (Mod dysplasia)... 6 HG SIL: CIN III (Severe/CIS)... 7 Microinvasive CA... 8 Invasive CA... 9 Adenocarcinoma - in - situ...10 Adenocarcinoma Other b. Vaginal None... 1 HPV lesion... 2 VAIN I... 3 VAIN II... 4 VAIN III... 5 Invasive CA... 6 Other... 7 c. Vulvar None... 1 HPV lesion... 2 VIN I... 3 VIN II... 4 VIN III... 5 Invasive CA... 6 Other... 7 d. Perianal None... 1 HPV lesion... 2 PAIN I... 3 PAIN II... 4 PAIN III... 5 Invasive CA... 6 Other... 7 Page 2 of 8
3 e. Anal None... 1 HPV lesion... 2 AIN I... 3 AIN II... 4 AIN III... 5 Invasive CA... 6 Other... 7 f. Endometrium None... 1 Atypical hyperplasia... 2 Invasive CA... 3 Other... 4 g. Other Location: Yes... 1 No... 2(A6) i. Location ii. Lesion A6. INDICATION FOR TREATMENT BASED ON: (circle yes or no for each indication) a. Suspicious pap smear with inadequate colposcopy b. Histologic diagnosis c. Pap smear - histologic - colposcopic discrepancy d. Abnormal colposcopy e. Grossly apparent lesion f. Other Page 3 of 8
4 A7. TREATMENT MODALITY: a. Cervix (circle yes or no for each modality) 1. None/Observation... 1(b) 2 2. Interferon FU Cryotherapy Laser vaporization Laser conization LEEP/LLETZ (transformation zone) LEEP conization Cold - knife conization Hysterectomy (simple) Hysterectomy (radical) Radiation therapy Other b. Vagina (circle yes or no for each modality) 1. None/Observation... 1 (c) 2 2. TCA Podophyllin Condylox Interferon FU Cryotherapy Laser vaporization LEEP Vaginal excision (local) Vaginectomy Radiation therapy Other Page 4 of 8
5 c. Vulva (circle yes or no for each modality) 1. None/Observation... 1 (d) 2 2. TCA Podophyllin Condylox Interferon FU Cryotherapy Laser vaporization LEEP Wide local excision Vulvectomy Radiation therapy Other \ d. Perianal (circle yes or no for each modality) 1. None/Observation... 1 (e) 2 2. TCA Podophyllin Condylox Interferon FU Cryotherapy Laser vaporization LEEP Excision Radiation therapy Other Page 5 of 8
6 e. Anal (circle yes or no for each modality) 1. None/Observation... 1 (f) 2 2. TCA Podophyllin Condylox Interferon FU Cryotherapy Laser vaporization LEEP Excision Radiation therapy Other f. Endometrium (circle yes or no for each modality) 1. None/Observation... 1 (g) 2 2. Hormone therapy Dilation and Curettage (D&C) Hysterectomy (simple) Hysterectomy (radical) Radiation therapy Other g. Other Location: Yes... 1 No... 2(A8) i. Location: ii. Modality Page 6 of 8
7 A8. IS THIS PATIENT PART OF ATHER STUDY EVALUATION FOR TREATMENT OF DYSPLASIA? (A9) a. SPECIFY NAME OF STUDY:_ b. SPECIFY NAME OF STUDY SITE: A9. WAS HISTOLOGIC EVALUATION OBTAINED OR BIOPSY PERFORMED DURING THIS TREATMENT PROCEDURE?... 1 (Complete Form L15 for each biopsy performed)... 2 A10. FOLLOW UP SCHEDULED? (A11) UNKWN...<-8> (A11) a. INDICATE SCHEDULED FOLLOW-UP IN WEEKS OR MONTHS: WEEKS... 1 MONTHS... 2 b. INDICATE TYPE OF FOLLOW-UP PLANNED: A11. WAS TREATMENT COMPLETED TODAY? Repeat pap only... 1 Repeat pap & colposcopy... 2 Repeat colposcopy only... 3 Repeat treatment Other... 5, Complete... 1, Incomplete... 2 Ongoing... 3 Delayed... 4 Other... 5 Refused... <-7> Unknown... <-8> Page 7 of 8
8 A12. HOW WAS THIS INFORMATION OBTAINED? (circle yes or no for each source) a. Study personnel b. Chart abstraction c. Direct contact with provider d. Patient history e. Other A13. INDICATE PRIMARY SOURCE OF THIS INFORMATION? (code below even if only one source = yes at A12) a. Study personnel b. Chart abstraction c. Direct contact with provider d. Patient history e. Other A14. Name of person providing treatment on this date: (Please Print) A15. Institution (Name or Number): (Please Print) (ADDRESS) Page 8 of 8
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