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Family/Referring Doctor Name
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LMP
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Pregnant
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Diagnosis date of abnormal pap
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Pap smear results
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Pap smear comments
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HPV HR
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Prior Abnormal Pap
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Prior abnormal paps
• • •
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Prior abnormal pap details
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Colpo Satisfactory
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Colposcopy findings
• • •
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Colpo Findings comments
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Lesion site
• • •
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Lesion site comment
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Biopsy site
• • •
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# of EMBx passes made
• • •
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Biopsy Details
• • •
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Pelvic Diagram
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Assessment
• • •
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Assessment comment
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Plan
• • •
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Plan comments
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