Cervical History Questionnaire
The Cervical History Questionnaire was developed by the California Department of Health Services, Cancer Detection Section (CDS) with guidance from the Cervical Expert Workgroup (an expert panel of California clinicians). The cervical history questionnaire may be used by clinicians to assist in identifying whether to perform a fourth screening Pap test.
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Rationale and Background
"Why a fourth Pap?" The Centers for Disease Control and Prevention (CDC) funds the cervical component of the Cancer Detection Programs: Every Woman Counts through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). In 1999, CDC issued a policy related to decreasing over-screening among women enrolled in the NBCCEDP. This policy states that after a woman has had three, consecutive, normal, Pap tests within a 5-year (60 months) period, the Pap test shall be performed every 3 years at the discretion of the clinician. In response to the CDC policy the California Department of Health Services, Cancer Detection Section (CDS), in consultation with the Cervical Expert Workgroup, established guidelines to assist clinicians in deciding whether to perform a fourth consecutive Pap test. The Cervical History Questionnaire was developed to facilitate the collection of data relevant to these guidelines.
CDS Guidelines for considering a fourth consecutive Pap test:
- History of SIL (squamous intraepithelial lesions), or previous epithelial abnormality
- History of cervical dysplasia or cervical cancer, or treatment for cervical dysplasia or cervical cancer
- History of multiple partners, or relations with partners that have a history of multiple partners
- Women who smoke, or have a history of smoking within the past year
- Immunosuppression
- Sexually transmitted disease(s), or a history of sexually transmitted disease
- Early age at first intercourse
Using the Form
The Cervical History Questionnaire is intended to assist clinicians in determining whether to perform a fourth Pap test by facilitating the collection of data relevant to CDS Guidelines (please see above). (See also Rationale and Background.)
The questionnaire may be completed by either the patient or the clinician. (English/Spanish PDF) After the questionnaire is completed, the clinician dates and initials the block located at the bottom of the questionnaire. A clinician's initials indicate that they have discussed the completed questionnaire with the patient. The completed questionnaire should then be maintained in the medical record for as long as the patient remains enrolled in the Cancer Detection Programs: Every Woman Counts.
For additional assistance, please contact the clinical coordinator at your Regional Contractor's office .
Reviewed: February, 2006. |
