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Form Id: FRM_CANCER_SCR

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History
Does the client smoke Cigarettes ?:	YESNOSTOPPED
Number of years the client has smoked cigarretes:
Number of cigarretes the client smokes per day:
Other form of tobacco used by the client ?:	YESNOSTOPPED
Does the client take alcohol?:	YESNOSTOPPED
Client's HIV Status?:	POSITIVENEGATIVEUNKNOWN
Does the client have a family history of cancer?:	YesNo
Previous Cancer Treatment (other):
Chemotherapy:
Radiotherapy:
Surgery:
Hormonal therapy:
LMP Date:
Common Signs and Symptoms
None:
Dyspepsia:
Blood in stool:
Yellow eyes:
Blood in urine:
Nose Bleeding:
Difficulty in swallowing:
Weight loss:
Easy fatigability:
Abnormal vaginal bleeding:
Changing/enlarging skin moles:
Chronic skin ulcers:
Lumps/swellings:
Chronic cough:
Persistent headaches:
Changing bowel habits:
Post-coital bleeding:
Other (specify):
Screening
Visit Type:	Initial visitRoutine visitPost Treatment visitPost Treatment complication
Screening Type:	First Time ScreeningRe-Screeing after previous negative resultsPost treatment followup screening
Cancer Type NOT USED:
Cancer Type: Cervical:
Cancer Type: Breast:
Cancer Type: Colorectal:
Cancer Type: Retinoblastoma:
Cancer Type: Prostate:
Cancer Type: Oral cancer:
other 1 not used:
other 2 not used:
Colorectal
Test result for faecal occult blood test:	YesNo
Treatment (Occult blood):	Counseled on Negative findingsReferred for further evaluation
Colonoscopy:	No abnormalityPolypsSuspicoius for cancerInflammationOther abnormalities
Treatment for colonoscopy:	Counsel on negative findingsRefer to surgical resectionRefer for biopsyReferred for further management
Retinoblastoma
EUA (Examination Under Anesthesia):	Normal(-ve)Abnormal(+ve)
EUA Treatment:	Counseled on Negative findingsReferred for further evaluation
RB1 gene testing:	PositiveNegativeIndeterminate
RB Treatment:	Counseled on Negative findingsReferred for further evaluation
Prostate
DRE (Digital Rectal Examination):	NormalEnlargedHard/lampy
DRE Treatment:	Patient educationCounseled on -ve findingsafter (DRE, PSA test and TRUS) Perfromed/refferd for further evaluation(PSA,TRUS Biopsy)
PSA (Prostatic Specific Antigen) testing:	0-4ng/ml4-10ng/ml>10ng/ml
PSA Treatment:	Routine follow up after 2 yearsFurther evaluationPerform/refer for biopsy
Oral cancer
Visual Examination:	NormalAbnormal
Visual Examination Treatment:	Counseled on Normal findingsReferred for further evaluation
Cytology:	PositiveNegativeIndeterminate
Cytology Treatment:	Counseled on Normal findingsReferred for further evaluation
Imaging:	NormalAbnormal
Imaging Treatment:	Counseled on Negative findingsReferred for further evaluation
Biopsy:	NormalAbnormal
Biopsy Treatment:	Counseled on Negative findingsReferred for further evaluation
Post Treatment Complication Cause:
Other Post Treatment Complication:
Referral Reason:
Cervical
HPV Screening Result:	NegativePositiveSuspicious for Cancer
HPV Treatment:	Counseled on negative resultsRe-screen after 5 yearsRe-screening after 2 yearsDo a VIA or colposcopy
VIA/VILI Screening Result:	NegativePositiveSuspicious for Cancer
VIA/VILI Action:	Counseled for negative resultsRe-screen after 5 yearsRe-screening after 1 yearPerform biopsy and/or refer for further management
VIA/VILI Treatment:	Cryotherapy performedThermal ablation PerformedLEEP PerformedCold Knife ConeOther
PAP SMEAR Screening Result:	NormalLow grade lesionHigh grade lesionInvasive CancerAtypical squamous cells(ASC-US/ASC-H)AGUS
PAP SMEAR Treatment:	Counseled for negative resultsRescreen every 3-5 years
PAP SMEAR Referrals ordered:	Colposcopy Biopsy of Cervix
Colposcopy Treatment (for positive HPV,VIA or PAP smear)
Colposcopy Treatment (summary):	BiopsyCINIIandAboveBiopsyCINIIandBelowBiopsyNotAvailable
Colposcopy Findings:	NormalAbnormalSuspicious for Cancer
Counsel for negative results:
Re-screen after 5 years:
Re-screening after 2 years:
Treatment (Biopsy result is CIN II and above):	CryotherapyThermal ablationLoop electrosurgical excisionCryotherapy performed(SVA)Cryotherapy postponedCryotherapy Performed(Previously postponed)Referred for CryotherapyLEEP PerformedCold Knife coneThermal ablation Performed(SVA)HysterectomyReferred for Cancer Treatment
Rescreen after 3 Years (If results is CIN I or less):
Refer for appropriate diagnosis and management (If biopsy not available):
Breast
CBE (Clinical Breast Examination):	NormalAbnormal
CBE Treatment:	Counseled for negative findingsrefer for triple assessment
Ultrasound:	BIRADS 0(Incomplete Need additional imaging evaluation)BIRADS 1(Negative)BIRADS 2(Benign)BIRADS 3(Probably Benign)BIRADS 4(Suspicious)BIRADS 5(Highly Suggestive of Malignancy)BIRADS 6(Known Biopsy-Proven Malignancy)
Ultrasound Treatment:	Recall for additional imagingRoutine mammography screeningShort-interval(6 months) follow-upTissue Diagnosis(U/S guided biopsy)Referred for further managementTissue Diagnosis(U/S guided biopsy)
Tissue Diagnosis (U/S guided biopsy):	DoneNot done
Tissue Diagnosis Date:
Reason not done:
Follow Up
Follow Up date:
Referred:	YesNo
Referral Facility:
Reason for Referral:	Further evaluation Diagnostic work up Treatment Other (specify)
Other reason:
Clinical notes:

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