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  Appendix 3 / FORMAT FOR REPORTING RESULTS OF VIA AND VILI

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Screening with VIA and VILI
1.Clinic/Serial/Unique number[ ][ ] [ ][ ]
2.Date of testing (day (2 digits)-month (2 digits)-year (2 digits)):[ ][ ]-[ ][ ]-[ ][ ]
3. Name: ________________________________________________
4. Address: ______________________________________________
______________________________________________________
5. Age (in years) [ ][ ]
6. Education (1: Nil; 2: Primary; 3: Middle; 4: High school; 5: College; 9: Not known)[ ]
7.When did you have your last menstruation? (1: Less than 12 months ago; 2: More than 12 months ago)[ ]
8.Marital status: (1: Married; 2: Widowed; 3: Separated; 8: Other; 9: Not known)[ ]
9.Age at marriage or first sexual intercourse: (99, if not known)[ ][ ]
10.Total number of pregnancies/miscarriages:[ ][ ]
11.Do you suffer from the following? (use Y to indicate if the response is yes; otherwise, leave blank):
Excessive vaginal discharge [ ]
Itching in the external anogenitalia [ ]
Ulcers in the external anogenitalia [ ]
Lower abdominal pain [ ]
Pain during sexual intercourse [ ]
Bleeding after intercourse [ ]
Intermenstrual bleeding [ ]
Low back ache [ ]
12.Visual examination findings? (use Y to indicate if the response is yes; otherwise, leave blank):
Squamocolumnar junction fully seen[ ]
Cervical polyp[ ]
Nabothian follicles[ ]
Cervicitis[ ]
Leukoplakia[ ]
Condyloma[ ]
Growth[ ]
13.Findings one minute after application of 5% acetic acid (VIA) (1: Negative; 2: Positive; 3: Positive, invasive cancer)[ ]
14.If VIA positive, does the acetowhite lesion extend in to the endocervical canal? (1: Yes; 2: No)[ ]
15.If VIA positive, how many quadrants are involved in the acetowhite lesion(s)? (1: Two or less; 2: Three; 3: Four quadrants)[ ]
16.Diagram (Draw the location of the squamocolumnar junction with a dotted line and the acetowhite/iodine non-uptake area(s) as a continuous line)
17.Findings after application of Lugolís iodine (VILI) (1: Negative; 2: Positive; 3: Positive, invasive cancer)[ ]
18.If invasive cancer, stage (1: IA; 2: IB; 3: IIA; 4: IIB; 5: IIIA; 6: IIIB; 7: IVA; 8: IVB; 9: Not known)[ ]
19. Biopsy taken? (1: Yes; 2: No)[ ]
(If yes, indicate the biopsy site(s) in the diagram with Ďxí mark)
20.Action taken: (1: Advised follow-up after five years; 2: Advised medication for cervicitis and follow-up after six months; 3: Referred for colposcopy; 4: Referred for immediate treatment; 5: Referred for staging and treatment of invasive cancer; 7: Other, specify _________________________)[ ]
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