PATIENT #16
a, a a
Registered 2026-09-10 03:43:04
Republic of the Philippines
Bangsamoro Autonomous Region in Muslim Mindanao
MINISTRY OF HEALTH
Bangsamoro Government Center, Rosary Heights 7, Cotabato City, 9600
Tel: (064) 552-0086, 421-3988 Fax: (064) 421-6842
Personal Details and Consent
Last name
a
First name
a
Middle name
a
Region
BARMM
Province
Maguindanao Del Norte
Municipality
SULTAN KUDARAT (NULING)
Barangay
Crossing Simuay
Date of birth
1996-02-02
No. of children
1
Civil status
Married
Name of health facility
MOH Clinic
Other procedure(s)
Not recorded
Age
30
Gender
Female
Consent acknowledgment
Acknowledged
Procedures
VIA, HPV DNA testing
History Taking
First menstrual period (menarche)
Not recorded
Last menstrual period (LMP)
Not recorded
Age of gestation (AOG), if applicable
Not recorded
Menstrual bleeding pattern
Not recorded
No. of pads per day
Not recorded
Gravida (no. of pregnancies)
Not recorded
Parity (no. of deliveries)
Not recorded
No. of full-term deliveries
Not recorded
No. of pre-term deliveries
Not recorded
No. of abortions
Not recorded
No. of living children
Not recorded
Age at first full-term pregnancy
Not recorded
Oral contraceptives duration (previous and current): no. of years
Not recorded
Oral contraceptives duration: no. of months
Not recorded
History of previous cervical cancer screening
Not recorded
History of previous breast cancer early detection
Not recorded
History of abnormal vaginal discharge
Not recorded
History of abnormal vaginal bleeding
Not recorded
Age at first intercourse
Not recorded
No. of sexual partners
Not recorded
Spouse / partner(s)
Not recorded
STI history — client
Not recorded
STI history — spouse / partner
Not recorded
Family history of cancer
Not recorded
Smoking
Not recorded
Current medication
Not recorded
Allergies
Not recorded
Abdominal surgery
Not recorded
III. Physical Examination - Vital Signs and Anthropometric Measurements
Blood pressure (mmHg)
Not recorded
Temperature (°C)
Not recorded
Heart rate (beats/min)
Not recorded
Respiratory rate (breaths/min)
Not recorded
Height (cm)
Not recorded
Weight (kg)
Not recorded
BMI (kg/m²)
Not recorded
Skin and HEENT
Skin: Pallor
Not recorded
Skin: Rashes
Not recorded
Skin: Jaundice
Not recorded
HEENT: Anicteric sclerae
Not recorded
HEENT: Aural discharge
Not recorded
HEENT: Nasal discharge
Not recorded
Neck findings
Not recorded
Chest, Heart and Abdomen - For Doctors / Trained Health Care Providers
Chest and lungs: Clear breath sounds
Not recorded
Chest and lungs: Crackles / rales
Not recorded
Chest and lungs: Wheezes
Not recorded
Heart: Normal rate
Not recorded
Heart: Regular rhythm
Not recorded
Heart: Murmur
Not recorded
Abdomen: Scars
Not recorded
Abdomen: Stretch marks
Not recorded
Abdomen: Presence of mass
Not recorded
Abdomen: Enlarged liver
Not recorded
Abdomen: Tenderness
Not recorded
Abdomen: Presence of fluid wave
Not recorded
Breast Examination
Breast findings: Mass
Not recorded
Breast findings: Nipple discharge
Not recorded
Breast findings: Skin-orange peel or dimpling
Not recorded
Breast findings: Enlarged axillary lymph nodes
Not recorded
Right breast
Not recorded
Left breast
Not recorded
Pelvic Examination
Vulva: Redness (inflammation)
Not recorded
Vulva: Tenderness
Not recorded
Vulva: Ulcers
Not recorded
Vulva: Blisters
Not recorded
Vulva: Warts
Not recorded
Vulva: Cyst
Not recorded
Vulva: Skin tags
Not recorded
Other vulvar mass - specify
Not recorded
Bartholin’s and Skene’s glands: Swelling
Not recorded
Bartholin’s and Skene’s glands: Tenderness
Not recorded
Bartholin’s and Skene’s glands: Discharge
Not recorded
Speculum exam: Vaginal or cervical lesion
Not recorded
Speculum exam: Tears
Not recorded
Speculum exam: Ulcers
Not recorded
Other speculum abnormalities
Not recorded
Pelvic Examination - For Doctors / Trained Health Care Providers
Bimanual exam - size
Not recorded
Bimanual exam - shape
Not recorded
Position of uterus
Not recorded
Bimanual findings: Cervical motion tenderness
Not recorded
Bimanual findings: Adnexal masses or tenderness
Not recorded
Recto-vaginal exam (if the bimanual is confusing)
Not recorded
IV. Screening Results
VIA findings
Not recorded
VIA result
Suspect cancer
Pap smear / HPV DNA results
Not recorded
V. Counselling Given
Counselling given
Not recorded
VI. Treatment and Other Care Given
Treatment and other care given
Not recorded
VII. Referral
Referral notes
Not recorded
Printed name of health care provider
Not recorded
VIA Screening Result
VIA result
Suspect cancer
Examined by
Michelle Lu
Examination date
2026-09-10
Remarks
none