CERVICAL CANCER OPERATIVE CARE and POSTOP COMPLICATIONS WITHIN 30 DAYS Data Collection Form January 12, 2015
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CERVICAL CANCER OPERATIVE CARE AND POSTOP COMPLICATIONS WITHIN 30 DAYS Data Collection Form January 12, 2015 I. PATIENT DEMOGRAPHICS Medical Record Number Date of Birth Zip Code White/Caucasian Asian Native Hawaiian/Pacific Islander Unknown Race (select all applicable) African American American Indian/Alaskan Native Hispanic/Latino/Spanish Chose Not to Disclose II. CERVICAL CANCER SCREENING Date of screening ____________________ Is patient U.S. born: Yes No Unknown Has patient seen a healthcare provider in the past 5 years? Yes No Has patient ever had a pregnancy? Yes No How many pregnancies has the patient had altogether? (include all pregnancies including those ending Date of most recent pregnancy: ___________ in live birth, miscarriage, abortion, still birth, and ectopic pregnancies.) _____________________________ Did a pregnancy delay disease management? Yes No Has patient had a Pap test in the past 5 years? Yes No (If yes, please complete table below for all Pap results in the past 5 years) Date of Type of Lab Image- Performed by Satisfactory Endocervical/ Pap result Was patient Date of Was Treated for Date of Type of Performed by Pap Pap where based test result? TZ referred to colposcopy colposcopy an abnormal abnormal treatment run? evaluation? component colposcopy? satisfactory? PAP or PAP or (Name) present? cervical cervical received biopsy in the biopsy past 5 treatment years? Family Family practice practice Normal Primary care Primary care (NILM) LEEP STM/ Yes physician Yes physician ASC-US Yes Cold knife Glass slide No Gynecologist No Yes Yes No Gynecologist LSIL No cone ThinPrep Not Gyn/onc Not No Not reported Yes No Gyn/onc HSIL Not CO2 Laser SurePath indicated Advanced indicated Not indicated Advanced AGC indicated therapy __/___/___ MM/DD/YEAR Practice Clinician __/___/___ MM/DD/YEAR __/___/___ MM/DD/YEAR Practice AIS Cryo (APN,PA, NP) Clinician Other (specify) (APN,PA, NP) Other (specify) Family Family practice practice Normal Primary care Primary care (NILM) LEEP STM/ Yes physician Yes physician ASC-US Yes Cold knife Glass slide No Gynecologist No Yes Yes No Gynecologist LSIL No cone ThinPrep Not Gyn/onc Not No Not reported Yes No Gyn/onc HSIL Not CO2 Laser SurePath indicated Advanced indicated Not indicated Advanced __/___/___ MM/DD/YEAR AGC indicated __/___/___ MM/DD/YEAR therapy Practice Clinician __/___/___ MM/DD/YEAR Practice AIS Cryo (APN,PA, NP) Clinician Other (specify) (APN,PA, NP) Other (specify) Family Family practice practice Normal Primary care Primary care (NILM) LEEP STM/ Yes physician Yes physician ASC-US Yes Cold knife Glass slide No Gynecologist No Yes Yes No Gynecologist LSIL No cone ThinPrep Not Gyn/onc Not No Not reported Yes No Gyn/onc HSIL Not CO2 Laser SurePath indicated Advanced indicated Not indicated Advanced AGC indicated therapy __/___/___ MM/DD/YEAR __/___/___ MM/DD/YEAR __/___/___ MM/DD/YEAR Practice Clinician Practice AIS Cryo (APN,PA, NP) Clinician Other (specify) (APN,PA, NP) Other (specify) Family Family practice practice Primary care Normal Primary care physician (NILM) LEEP STM/ Yes Yes physician Gynecologist ASC-US Yes Cold knife Glass slide No No Yes Yes No Gynecologist Gyn/onc LSIL No cone ThinPrep Not Not No Not reported Yes No Gyn/onc Advanced HSIL Not CO2 Laser SurePath indicated indicated Not indicated Advanced Practice Clinician AGC indicated therapy __/___/___ MM/DD/YEAR __/___/___ MM/DD/YEAR __/___/___ MM/DD/YEAR Practice (APN,PA, NP) AIS Cryo Clinician Other (specify) (APN,PA, NP) Other (specify) 1 81814SGO-0902 CERVICAL CANCER OPERATIVE CARE AND POSTOP COMPLICATIONS WITHIN 30 DAYS DATA COLLECTION FORM CONTINUED Has patient had an HPV in the past 5 years? Yes No (If yes, please complete table below for all HPV results in the past 5 years) Date of HPV Type of HPV Lab where HPV result HPV Results of Performed by Was patient Date of Was run? genotyping genotyping? referred to colposcopy colposcopy (Name) performed? colposcopy? satisfactory? Qiagen Family practice Cervista Primary care physician Positive HR Positive Roche Cobas HPV 16 Gynecologist Negative HR HPV 18 Negative Yes Yes No __/___/___ Aptima Gyn/onc __/___/___ No Not reported MM/DD/YEAR Indeterminate HPV 45 Not Reported MM/DD/YEAR Laboratory Advanced Practice Not Reported Not indicated Developed Test (LDT) Clinician (APN,PA, NP) Not Specified Other (specify)__________ Qiagen Family practice Cervista Primary care physician Positive HR Positive Roche Cobas HPV 16 Gynecologist Negative HR HPV 18 Negative Yes Yes No __/___/___ Aptima Gyn/onc __/___/___ No Not reported MM/DD/YEAR Indeterminate HPV 45 Not Reported MM/DD/YEAR Laboratory Advanced Practice Not Reported Not indicated Developed Test (LDT) Clinician (APN,PA, NP) Not Specified Other (specify)__________ Qiagen Family practice Cervista Primary care physician Positive HR Positive Roche Cobas HPV 16 Gynecologist Negative HR HPV 18 Negative Yes Yes No __/___/___ Aptima Gyn/onc __/___/___ No Not reported MM/DD/YEAR Indeterminate HPV 45 Not Reported MM/DD/YEAR Laboratory Advanced Practice Not Reported Not indicated Developed Test (LDT) Clinician (APN,PA, NP) Not Specified Other (specify)__________ Qiagen Family practice Cervista Primary care physician Positive HR Positive Roche Cobas HPV 16 Gynecologist Negative HR HPV 18 Negative Yes Yes No __/___/___ Aptima Gyn/onc __/___/___ No Not reported MM/DD/YEAR Indeterminate HPV 45 Not Reported MM/DD/YEAR Laboratory Advanced Practice Not Reported Not indicated Developed Test (LDT) Clinician (APN,PA, NP) Not Specified Other (specify)__________ Please complete table below for all results in the past 5 years Has patient had a uterus biopsy performed? Yes No Has patient had an anus biopsy performed? Yes No Has patient had a vulva biopsy performed? Yes No Has patient had a vagina biopsy performed? Yes No Has patient had a cervical biopsy performed? Yes No Complete all applicable tables. UTERUS Date of uterus biopsy test Uterus biopsy test results Performed by Family practice Normal Primary care physician AGUS ___/____/_____ Gynecologist MM/DD/YEAR Hyperplasia without atypia Gyn/onc Hyperplasia with atypia Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ Family practice Normal Primary care physician AGUS ___/____/_____ Gynecologist MM/DD/YEAR Hyperplasia without atypia Gyn/onc Hyperplasia with atypia Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ Family practice Normal Primary care physician AGUS ___/____/_____ Gynecologist MM/DD/YEAR Hyperplasia without atypia Gyn/onc Hyperplasia with atypia Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ Family practice Normal Primary care physician AGUS Gynecologist ___/____/_____ MM/DD/YEAR Hyperplasia without atypia Gyn/onc Hyperplasia with atypia Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ 2 81814SGO-0902 CERVICAL CANCER OPERATIVE CARE AND POSTOP COMPLICATIONS WITHIN 30 DAYS DATA COLLECTION FORM CONTINUED ANUS Date of Anus biopsy test Anus biopsy test results Performed by Family practice Normal Primary care physician Dysplasia – mild Gynecologist ___/____/_____ MM/DD/YEAR Dysplasia - moderate Gyn/onc Dysplasia - severe Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ Family practice Normal Primary care physician Dysplasia – mild Gynecologist ___/____/_____ MM/DD/YEAR Dysplasia - moderate Gyn/onc Dysplasia - severe Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ Family practice Normal Primary care physician Dysplasia – mild Gynecologist ___/____/_____ MM/DD/YEAR Dysplasia - moderate Gyn/onc Dysplasia - severe Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ Family practice Normal Primary care physician Dysplasia – mild Gynecologist ___/____/_____ MM/DD/YEAR Dysplasia - moderate Gyn/onc Dysplasia - severe Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ VULVA Date of Vulva biopsy test Vulva biopsy test results Performed by Family practice Normal Primary care physician VIN-1 Gynecologist ___/____/_____ MM/DD/YEAR VIN-2 Gyn/onc VIN-3 Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ Family practice Normal Primary care physician VIN-1 Gynecologist ___/____/_____ MM/DD/YEAR VIN-2 Gyn/onc VIN-3 Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ Family practice Normal Primary care physician VIN-1 Gynecologist ___/____/_____ MM/DD/YEAR VIN-2 Gyn/onc VIN-3 Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ Family practice Normal Primary care physician VIN-1 Gynecologist ___/____/_____ MM/DD/YEAR VIN-2 Gyn/onc VIN-3 Advanced Practice Clinician (APN,PA, NP) Cancer Other (specify)_________________________ 3 81814SGO-0902 CERVICAL CANCER OPERATIVE CARE AND POSTOP COMPLICATIONS WITHIN 30 DAYS DATA COLLECTION FORM CONTINUED VAGINA Date of Vagina biopsy test Vagina biopsy test results Performed by Family practice Normal Primary care physician AGUS Gynecologist ___/____/_____ VAIN-1 Gyn/onc MM/DD/YEAR VAIN-2 Advanced Practice Clinician (APN,PA, NP) VAIN-3 Cancer Other (specify)_________________________