CBC registration | Cervical & Breast Cancer Program

Complete the applicable history details. Additional fields appear when you select Yes; details marked * are required. For previous screening, enter the results available to you. Select Not applicable where available, enter N/A in text fields, or leave dates and numbers blank when not applicable. Hidden answers are retained for corrections but excluded from the review.

First menstrual period (menarche)

Last menstrual period (LMP)

Age of gestation (AOG), if applicable

Menstrual bleeding pattern

No. of pads per day

Gravida (no. of pregnancies)

Parity (no. of deliveries)

No. of full-term deliveries

No. of pre-term deliveries

No. of abortions

No. of living children

Age at first full-term pregnancy

Oral contraceptives duration (previous and current): no. of years

Oral contraceptives duration: no. of months

History of previous cervical cancer screening

Previous VIA result

Previous Pap smear result

Previous HPV DNA result

History of previous breast cancer early detection

Previous clinical breast exam (CBE) result

Previous mammography result

Previous breast ultrasound result

History of abnormal vaginal discharge

History of abnormal vaginal bleeding

Age at first intercourse

No. of sexual partners

Spouse / partner(s)

STI history — client

Client STI history — specify

STI history — spouse / partner

Spouse / partner STI history — specify

Family history of cancer

Family history of cancer — specify

Smoking

Smoking — year started

No. of cigarette sticks per day

Current medication

Current medication — specify

Allergies

Allergies — specify

Abdominal surgery

Abdominal surgery — specify

Edit patient #17

III. Physical Examination - Vital Signs and Anthropometric Measurements

Skin and HEENT

Skin

HEENT

Chest, Heart and Abdomen - For Doctors / Trained Health Care Providers

Chest and lungs

Heart

Abdomen

Breast Examination

Breast findings

Right breast

Left breast

Pelvic Examination

Vulva

Bartholin’s and Skene’s glands

Speculum exam

Pelvic Examination - For Doctors / Trained Health Care Providers

Bimanual findings

IV. Screening Results

VIA findings

V. Counselling Given

VI. Treatment and Other Care Given

VII. Referral

VIA screening diagram