Cytology Pathology Assessment Form
Please complete this form to document and assess cytology pathology cases accurately.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Gender
*
Male
Female
Other
Referring Physician/Clinic Name
*
Specimen Collection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Specimen Type
*
Please Select
Fine Needle Aspiration (FNA)
Pap Smear
Body Fluid
Urine Cytology
Other
Specimen Site/Source
*
Specimen Adequacy
*
Adequate
Unsatisfactory
Limited by
Cytological Features Assessment
*
Rows
Absent
Present
Atypical
Cellularity
1
2
3
Nuclear Pleomorphism
4
5
6
Mitotic Figures
7
8
9
Inflammation
10
11
12
Necrosis
13
14
15
Overall Diagnostic Interpretation
*
Negative for Malignancy
Atypical
Suspicious for Malignancy
Positive for Malignancy
Other (specify)
Comments / Additional Findings
Recommendations (if any)
Pathologist Name
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature (Pathologist)
*
Submit Assessment
Submit Assessment
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