Patient data collection form

QE II Research Institute for Mothers and Infants
Cecilia Ng
Department of Obstetrics, Gynaecology & Neonatology, USYD
30/01/2012
PATIENT DATA COLLECTION FORM
Royal Prince Alfred Hospital &
The University of Sydney
Attach Patient Label Here

Patient Study No.: QEII-12-_ _ _
Date of Surgery:
PECN-T/S _ _ _
_ _/_ _/_ _ _ _
FMB-_ _ _ NHKB-_ _ _ GD-_ _ _
PATIENT HISTORY
Day 1 of last menstrual period:

Menstrual cycle phase:
Early-

Obstetric Gynaecological History:
Gravida:

Symptoms: (Tick and fill details to all that apply)
Other (please specify):

Previous Diagnosis of Gynaecological Conditions: (Tick and fill details to all that apply)
Adenomyoma
Other (please specify):

Previous Gynaecological Surgery: (Tick and fill details to all that apply)
Nil
Ovarian cystectomy Other (please specify):

Medical Treatment: (Tick and fill details to all that apply)
Other (please specify):

Smoking/Alcohol: (Tick all that apply)
Smoking:
Alcohol:
PRESENT PATIENT SURGERY DETAILS
Surgery: (Tick and fill details to all that apply)
Hysterectomy
OGE Template - Patient Data Collection Form V5-2012.doc QE II Research Institute for Mothers and Infants
Cecilia Ng
Department of Obstetrics, Gynaecology & Neonatology, USYD
30/01/2012

PATIENT DIAGNOSIS PATHOLOGY DETAILS
Diagnosis: (Tick and fill details to all that apply)
· ENDOMETRIOSIS cases only: (Indicate on diagram type and location of endometriosis lesions)
Key to use:
OvCy = Ovarian cyst
PE = Peritoneal lesion
DIE = Deep-infiltrating lesion
RF = Red flare lesions
BN = Black nodules
WN = White nodules
Sc = Scarring
FA = Filmy adhesions
DA = Dense adhesions
FFCy = Fluid filled cysts
Other locations:
Endometriosis
Stage (rASRM):

· FIBROID/LEIOMYOMA:
Submucosal

· POLYPS:
Endometrial

· OTHER PATHOLOGIES:
Normal pelvic
Others (please specify):

Endometrial curetting/biopsy sent to RPAH Anatomical Pathology (circle): Yes / No
Endometriosis lesion(s) biopsy sample(s) sent to RPAH Anatomical Pathology (circle): Yes / No
Samples Collected for QEII Tissue Bank: (Number accordingly with roman numerals [exception for Blood,
Urine and Peritoneal Fluid] & Tick all that apply)
Endometrial
OGE Template - Patient Data Collection Form V5-2012.doc

Source: http://www.mjwcooper.com.au/attachments/article/58/OGE%20Template%20-%20Patient%20Data%20Collection%20Form%20V5-2012.pdf