COLPOSCOPY PROCEDURE FORM
J. Greg Hinson, M.D. • COLPOSCOPY PROCEDURE FORM
Date:
Name:
Phone #:
Referring Physician:
Indication for Colposcopy:
HISTORY: Age:_________ LMP:____________ uHCG: q pos. q neg.
Smoker: q yes q no Birth Control Method:
Abnormal Pap and Colposcopy History:
COLPOSCOPIC EXAMINATION: VITALS: WT:_________ BP:__________
q Satisfactory q Unsatisfactory Gross observations:
Pap repeated: q yes q no
LANDMARKS and ATYPICAL FINDINGS:
TZ = transformation zone SC = new squamocolumnar junction
NC = Nabothian cyst ME = immature squamous metaplasia
PO = polyp AV = atypical vessels
C = condyloma L = leukoplakia
AW = acetowhite epithelium P = punctation
MO = mosaicism LS = decreased Lugol’s uptake
X = biopsy sites CA = invasive carcinoma
ECC performed: q yes q no Reid’s Colposcopic Index:
Margin
IMPRESSIONS: Color
Vessels
Iodine
Total
RESULTS: Biopsy pathology_____________________________ ECC pathology
Repeat Pap
FOLLOW-UP:
PLAN:
Examiner
................
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