1. Periodic Woman Screening Sheet By Periodic Woman Screening Committee January 2010

2. Page 1 History Social and sexual History Occupation ------------ Education ------------- Exercise ------------------------------------------------- Smoking No Yes -------- packs/ day Alcohol intake No Yes ---- drinks/ week Post-coital bleeding No Yes Marital status Single married Widow divorced Age at marriage/ First sexual contact ----------

3. Page 1 History Menstrual History Age at first menarche: ------ Date of LMP:---------------- Duration: --------- regular irregular Menopause: No Yes Duration ----------- Use of HRT No Yes Duration -----------

4. Obstetric history: Para ------- Abortion -------- Age at first completed pregnancy --- Breast feeding No Yes Duration -------------- Contraception use Hormonal No Yes Duration ---------

5. Past medical history Date of last Clinical breast examination ------- Normal Abnormal Date of last mammography ---------------- Normal Abnormal No. of Breast biopsies (if done) --------- specify findings ----------------------- Date of last pap smear ----------------------- Normal Abnormal

6. History of breast cancer Yes No History of cervical cancer Yes No History of STI No Yes specify ----------------------------- Family History of first degree relatives with breast cancer No Yes No.-----

7. Physical Examination BP Height (m) Weight (Kg) BMI (Kg/) Neck Normal Abnormal Breast Normal Abnormal Axillary lymphadenopathy Normal Abnormal Abdomen Normal Abnormal Pelvic examination Normal Abnormal Speculum examination Normal Abnormal Other physical examination---------------------------- Comments -------------------------------------------------- -----------------------------------

8. Investigation requested/ results Pap smear Normal Abnormal HVS Normal Abnormal Mammography Normal Abnormal Others--------------------------------------------------- --------------------------------------------------------- Treatment ------------------------------------------------------------- --------------------------------------------------------- Referral ------------------------------------------------------------------------ ------------------------------------------------------------------

9. Breast cancer screening guidelines summary Major components of breast screening program at primary health care: Breast Self –Examination (BSE): to be performed once each month, beginning at age 20 and continue each month throughout a women's life time. Clinical Breast Examination (CBE): do CBE for women from the age of 20, as a part of her routine check-up every three years, increasing to once a year from the age of 40 and above. Mammography: To screen all women 40 years or above once every two years.

10. Cervical cancer screening guidelines Frequency of cervical screening Periodic women screening should be started three years after the onset of sexual activity or at 21 years of age whichever comes first. Those women with high risk of cervical cancer should have Pap smear annually. When to refer to SMC for colposcopy 2 Consecutive incidence of ASC-U ASC-H HSIL AGC-NOS Endometrial cells in 40 years or above

11. Thank You