Appendix 3 / Format for reporting results of VIA and VILI

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 Lugol’s 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 ‘x’ 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 _________________________)	[ ]