Colposcopic Vulvar Examination
Patient name: Last:
First:
DOB:
PHN:
PRIMARY PHYSICIAN:
REFERRING PHYSICIAN:
EXAM DATE:
HISTORY:
Smoker:
Yes
No
Parity:
LMP
Pregnant:
Yes
No
Menopausal:
Yes
No
HRT:
Yes
No
HPV Vaccine:
Yes
No
Date:
Number of Doses:
Pap: Most Recent Date:
Result:
Previous Treatment to the Cervix:
Yes
No
Date:
LEEP
Cryo
Laser
Pathology:
Discharged from the Colposcopy Clinic:
Yes
No
Date:
Reason for Referral:
New Visit:
Yes
No
Follow Up Visit:
Yes
No
Longterm Surveillance:
Yes
No
Previous Diagnosis:
Previous Treatment of Vulvar Disorders:
Yes
No
Date:
Details:
Presenting Vulvar Problem:
Pain
Pruritis
Visible Lesion
Clinical Findings:
Vulvar Examination:
Visible Description:
Size of Lesion:
Inguinal Lymph Nodes:
Yes
No
Suspicious:
Yes
No
Biopsy:
Yes
No
Type:
Keye's Punch
Cervical Punch
Excision
Local Anaesthetic:
Yes
No
Type:
Lidcaine Without
Lidcaine With
Marcaine Without
Marcaine With
Volume:
ml.
Suture:
Yes
No
Adverse Reaction:
Yes
No
Describe:
Vaginal Exam
Not Done
Normal
Abnormal
Cervical Exam
Not Done
Normal
Abnormal
Clinical Impression
Biopsy Result
Final Evaluation
Recommendations
Date:
Treatment (Describe):
Booked by Colposcopist:
Yes
No
Repeat Colposcopy Booked:
Yes
No
# Months:
Referred to BCCA:
Yes
No
Date:
Gynecological Consult:
Yes
No
Date:
Return to Primary Care:
Yes
No
Date:
Name:
MSC # :
Signature:
“Electronically Signed”
Subject:
created June 28
th
2020 by
Dr. John Robertson
,
licensed under a
GPL
.
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