LABORATORY - PELVIC EXAM STUDIES COLPOSCOPY RESULTS FORM L4 ID LABEL HERE ---> - - - VISIT #: FORM COMPLETED BY: VERSION DATE: 08/5/94 ANY MISSING OR INCOMPLETE TEST RESULTS MUST BE EXPLAINED ON THIS FORM. A. DATE OF PROCEDURE: / / M D Y A. TYPE OF COLPOSCOPY PERFORMED: YES NO a. Cervical b. Vaginal c. Vulvar d. Perianal A3. WAS CERVIX PRESENT? COLPOSCOPY RESULTS: YES... NO... (SKIP TO A9) A4. EXAM ADEQUACY: SATISFACTORY... ENDOCERVICAL SPECULUM USED TO VISUALIZE SQUAMOCOLUMNAR JUNCTION... TRANSFORMATION ZONE NOT VISUALIZED... 3 WIHS Laboratory Form L4: Pelvic Exam Studies (Colposcopy Results) - 08/5/94 Page of 9
A5. GENERAL CATEGORIZATION: WITHIN NORMAL LIMITS... (A7) ABNORMAL FINDINGS... A6. ATYPICAL TRANSFORMATION ZONE FOUND NOT FOUND a. Keratosis b. Aceto-White Epithelium c. Punctation d. Mosaicism e. Atypical Vessels A7. WHAT PERCENT (%) OF TRANSFORMATION ZONE WAS ABNORMAL? < 5%... 5% - < 50%... 50% - < 75%...3 75% - 00%...4 A8. What quadrants are abnormal? YES NO 9 Inner upper left quadrant... 0 Inner lower left quadrant... Inner lower right quadrant... Inner upper right quadrant... 3 Outer upper left quadrant... 4 Outer lower left quadrant... 5 Outer lower right quadrant... 6 Outer upper right quadrant... WIHS Laboratory Form L4 - Pelvic Exam Studies (Colposcopy Results) - 08/5/94 Page of 9
OTHER FINDINGS FOUND NOT FOUND LOCATION IF FOUND YES NO A9. Inflammation (A0) a. Vaginal b. Cervical c. Vulvar d. Perianal A0. Papilloma (A) a. Vaginal b. Cervical c. Vulvar d. Perianal A. Other (SPECIFY): a. (A) a. Vaginal b. Cervical c. Vulvar d. Perianal e. Anal A. Other (SPECIFY): a. (A3) a. Vaginal b. Cervical c. Vulvar d. Perianal e. Anal A3. WAS PAP SMEAR PERFORMED WITH THIS COLPOSCOPY? YES... NO... WIHS Laboratory Form L4 - Pelvic Exam Studies (Colposcopy Results) - 08/5/94 Page 3 of 9
A4. CERVICAL BIOPSY TAKEN? YES... NO... (SKIP TO A5) DELAYED...3 (SKIP TO A5) REFUSED... <-7> (SKIP TO A5) YES NO a. Endocervical Curettage... b. Cervical Cone Biopsy... (c) (CIRCLE TYPE) Loop... Laser... Cold Knife... 3 c. Loop Excision of Transformation Zone (LLETZ, LETZ, LEEP)... d. Colposcopically Directed Punch Biopsy... (e) i) Number of punch biopsies taken: ii) Location(s) taken: (round to nearest o'clock) a. o'clock b. o'clock c. o'clock d. o'clock e. Cervical Excisional Biopsy (other than punch biopsy)... (A4) i) Location taken: o'clock to o'clock A5. Overall impression of Cervix (Circle the highest grade lesion). NORMAL... ABNORMAL, BUT NO SIL... LOW GRADE... 3 HIGH GRADE... 4 INVASIVE... 5 WIHS Laboratory Form L4 - Pelvic Exam Studies (Colposcopy Results) - 08/5/94 Page 4 of 9
A6. OTHER NON-CERVICAL BIOPSIES TAKEN? YES... NO... (SKIP TO A) DELAYED...3 (SKIP TO A) REFUSED... <-7> (SKIP TO A) TYPE BIOPSIES TAKEN ENTER UP TO LOCATION YES NO CODES FOR EACH TYPE A7. Vaginal... (A8) a) b) A8. Vulvar... (A9) a) b) A9. Perianal... (A0) a) b) A0. Endometrial... (A) a) b) A. Anal... (A) b) c) LOCATION CODES ARE LOCATED ON PAGE 6 WIHS Laboratory Form L4 - Pelvic Exam Studies (Colposcopy Results) - 08/5/94 Page 5 of 9
LOCATION CODES. Labia Majus (left) 7. Anus upper left. Labia Majus (right) 8. Anus lower left 3. Labia Minus (left) 9. Anus lower right 4. Labia Minus (right) 30. Anus upper right 5. Introitus (left) 3. Internal Anus 6. Introitus (right) 7. Perineum (left) 8. Perineum (right) 9. Inguinal (left) 0. Inguinal (right). Thigh (left) Thigh (right) 3. Clitoris 4. Urethra 5. Pubis LOCATION CODES. Anterior vaginal wall, proximal third.. Anterior vaginal wall, medial third 3. Anterior vaginal wall, distal third 4. Left lateral vaginal wall, proximal third 5. Left lateral vaginal wall, medial third 6. Left Lateral vaginal wall, distal third 7. Posterior vaginal wall, proximal third 8. Posterior vaginal wall, medial third 9. Posterior vaginal wall, distal third 0. Right lateral vaginal wall, proximal third. Right lateral vaginal wall, medial third. Right lateral vaginal wall, distal third WIHS Laboratory Form L4 - Pelvic Exam Studies (Colposcopy Results) - 08/5/94 Page 6 of 9
A. OVERALL IMPRESSION: (CIRCLE THE HIGHEST NON-CERVICAL GRADE LESION) NORMAL... (A4) ABNORMAL, BUT NO SIL... LOW GRADE... 3 HIGH GRADE... 4 INVASIVE... 5 A3. LOCATION OF THE HIGHEST GRADE NON-CERVICAL LESION: YES NO a) Vagina... b) Vulva... c) Perianal... d) Anal... WIHS Laboratory Form L4 - Pelvic Exam Studies (Colposcopy Results) - 08/5/94 Page 7 of 9
A4. CIRCLE THE NUMBERS FOR THE LESION LOCATIONS: LOCATION CODES. Labia Majus (left) 7. Anus upper left. Labia Majus (right) 8. Anus lower left 3. Labia Minus (left) 9. Anus lower right 4. Labia Minus (right) 30. Anus upper right 5. Introitus (left) 3. Internal Anus 6. Introitus (right) 7. Perineum (left) 8. Perineum (right) 9. Inguinal (left) 0. Inguinal (right). Thigh (left) Thigh (right) 3. Clitoris 4. Urethra 5. Pubis A5. CIRCLE THE NUMBERS FOR LESION LOCATIONS: LOCATION CODES. Anterior vaginal wall, proximal third.. Anterior vaginal wall, medial third 3. Anterior vaginal wall, distal third 4. Left lateral vaginal wall, proximal third 5. Left lateral vaginal wall, medial third 6. Left Lateral vaginal wall, distal third 7. Posterior vaginal wall, proximal third 8. Posterior vaginal wall, medial third 9. Posterior vaginal wall, distal third 0. Right lateral vaginal wall, proximal third. Right lateral vaginal wall, medial third. Right lateral vaginal wall, distal third WIHS Laboratory Form L4 - Pelvic Exam Studies (Colposcopy Results) - 08/5/94 Page 8 of 9
A6. DID YOU KNOW THE HIV STATUS AT THE TIME OF THIS EXAM? YES... NO... A7. WAS FOLLOW-UP VISIT SCHEDULED FOR BIOPSY? YES... NO... a) SPECIFY WHERE SCHEDULED: (M.D. OR INSTITUTION) (ADDRESS) WIHS Laboratory Form L4 - Pelvic Exam Studies (Colposcopy Results) - 08/5/94 Page 9 of 9