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Date of Diagnosis: 
Day
Month
Year
 
 

Mutation status:

Smear result (tick whatever is appropriate in country of origin):

HPV status (locally assessed):
Day
Month
Year
 
 

Test used:

Outcome:

Genotype if positive:

Staging:

Histology:

Grade:

Surgery

Radiotherapy:

Systemic Therapy:

Alive (NO recurrence) – Date:
Day
Month
Year
 
 

Recurrence – Date:
Day
Month
Year
 
 

Death – Date:
Day
Month
Year