Patient

Name:

CYTOPATHOLOGY
PAP TEST REQUISITION

750 East Adams Street Syracuse, NY 13210

Department of Pathology

last

first

Date of Birth

Medical Record Number

Date collected:

Robert Corona, Jr., D.O., Chairman

Kamal K. Khurana, M.D., Director of Cytopathology
Phone (315) 464-4270 Fax (315) 464-4267

Account Number/Location

750 East Adams Street Syracuse, NY 13210

Department of Pathology

name

first

Date of Birth

middle

Medical Record Number

name

signature

Copy to:

SAMPLE METHOD (Check one): l ThinPrep Pap Test l Surepath Pap Test l Other, specify:
SPECIMEN SOURCE (Check those that apply): l Cervical l Endocervical l Vaginal l Anal-Rectal
ANCILLARY TEST REQUESTS: High risk HPV testing requested for following Pap results (check one):

l ASCUS/LGSIL (21-29 years) l Regardless

l Negative/ASCUS/LGSIL (>30 years)

Other ancillary test requests (specify):

l ASCUS/LGSIL (21-29 years) l Regardless

Other ancillary test requests (specify):

CLINICAL INFORMATION: (Check one)

CLINICAL INFORMATION: (Check one)

l Routine l High Risk l Diagnostic/ Symptomatic: ICD code/s:

List symptom/s:

l Routine l High Risk l Diagnostic/ Symptomatic: ICD code/s:

List symptom/s:

Last Menstrual Period:

Hysterectomy: (If yes, date):
l Cycling l Pre-natal: l 1st l 2nd l 3rd Trimester l Post Partum
l Peri-menopausal l Post Menopausal l Hormone Replacement
l Oral contraceptives l Patch l Depo l IUD l Tubal ligation l Other:

Last Menstrual Period:

Hysterectomy: (If yes, date):
l Cycling l Pre-natal: l 1st l 2nd l 3rd Trimester l Post Partum
l Peri-menopausal l Post Menopausal l Hormone Replacement
l Oral contraceptives l Patch l Depo l IUD l Tubal ligation l Other:

PREVIOUS ABNORMAL PAP TESTS:

l YES l NO (If yes, date):

Diagnosis:

PREVIOUS ABNORMAL PAP TESTS:

l YES l NO (If yes, date):

Diagnosis:

TREATMENT/ BIOPSY: Date:

Type:

TREATMENT/ BIOPSY: Date:

Type:

Diagnosis:

LAST PAP TEST: Date:

Where:
l Negative l Reactive l ASCUS l AGUS l LGSIL l HGNE l HGSIL l Unsatisfactory l Unavailable

P lease do not w rite belo w this line - - L aboratory Wor k space

Laboratory Interpretation:
l Yes

Transformation zone present:

Category: l NILM
Interpretation:
l REACT
l ASCUS

l ECA

Laboratory Interpretation:
l No

l N/A (Satisfactory)

l OTHER (EMC45)

l ASCUS-HGNE

l AGUS

l UNSAT:
l LGSIL

l LGSIL & ASC-H

40349 Reviewed 9/2015 Rev. 9/2015

l Yes

Transformation zone present:

l HGSIL

l CA:

Other findings:

Diagnosis:

LAST PAP TEST: Date:

Where:
l Negative l Reactive l ASCUS l AGUS l LGSIL l HGNE l HGSIL l Unsatisfactory l Unavailable

P lease do not w rite belo w this line - - L aboratory Wor k space

Category: l NILM
Interpretation:
l REACT
l ASCUS

l ECA

l No

l N/A (Satisfactory)

l OTHER (EMC45)

l ASCUS-HGNE

l AGUS

l UNSAT:
l LGSIL

l LGSIL & ASC-H

l HGSIL

l CA:

Other findings:

Cytotechnologist

Resident/ Fellow

Pathologist

40349 Reviewed 9/2015 Rev. 9/2015

Cytotechnologist

Resident/ Fellow

maiden

Account Number/Location

Collected by:

Ordering clinician:

Lab Accession No:

SAMPLE METHOD (Check one): l ThinPrep Pap Test l Surepath Pap Test l Other, specify:
SPECIMEN SOURCE (Check those that apply): l Cervical l Endocervical l Vaginal l Anal-Rectal
ANCILLARY TEST REQUESTS: High risk HPV testing requested for following Pap results (check one):

last

Date collected:

Robert Corona, Jr., D.O., Chairman

Kamal K. Khurana, M.D., Director of Cytopathology
Phone (315) 464-4270 Fax (315) 464-4267

signature

Copy to:

l Negative/ASCUS/LGSIL (>30 years)

maiden

Collected by:

Ordering clinician:

Lab Accession No:

middle

Patient
Name:

CYTOPATHOLOGY
PAP TEST REQUISITION

Pathologist