Annex: Sample VIA Screening Form
Name of Screening Centre
PERSONAL DETAILS & CONTACT INFORMATION
1. Unique registration ID: [ ][ ][ ][ ][ ][ ]
2. Date of registration (day/month/year): [ ][ ]/[ ][ ]/[ ][ ][ ][ ]
3. Last name: _________________________________
4. First name: _________________________________
5. Husband’s name
6. Age: [ ][ ]
7. Date of birth (day/month/year): [ ][ ]/[ ][ ]/[ ][ ][ ][ ]
Address: _________________________________
8. _________________________________
_________________________________
9. Telephone number: [ ][ ][ ][ ][ ][ ][ ][ ][ ][ ]
10. REGISTRATION NUMBER
REPRODUCTIVE HISTORY
1. Age at marriage or first sexual intercourse (in years): [ ][ ]
2. Total number of pregnancies: [ ][ ]
3. Last menstruation: (1. Less than 1 year; 2. More than 1 year; 9. Unknown) [ ]
4. Date of onset of last menstruation [ ][ ]/[ ][ ]/[ ][ ][ ][ ]
VIA PROCEDURE
1. SCJ visible: (1. Fully visible; 2. Partially visible; 3. Not visible) [ ]
2. Findings of VIA: (1. Not done; 2. Negative; 3. Positive; 4. Suspicious of invasive cancer) [ ]
3. If positive, size of the acetowhite area (% of ectocervix): (1. <25%; 2. 25–50%; 3. 50–75%; 4. >75%) [ ]
4. Can the lesion be covered by the cryotherapy probe? (1. Yes; 2. No) [ ]
5. Is the lesion suitable for cryotherapy? (1. Yes; 2. No) [ ]
TREATMENT
1. Thermal ablation: (1. Not required; 2. Not suitable; 3. Performed; 4. Refused; 5; Not done due to other reason) [ ]
2. Problem during thermal ablation: (1. None; 2. Pain; 3. Other; 4. Could not be completed) [ ]
3. Next follow-up date [ ][ ]/[ ][ ]/[ ][ ][ ][ ]
REFERRAL
1. Reason for referral (1. VIA +ve & not suitable for cryo; 2. VIA +ve & cryo not available; 3. Suspicious of cancer) [ ]
2. Referred to:
Name of Health Worker/Nurse Signature & date
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