The information that is important in rendering a halachic ruling is summarized in the following list of questions. This form can be printed out as a written report whose completion will minimize the chance of errors in transmission. Click here, for the printable form.
Name of procedure / type of examination: ______________
1. Must the examination or procedure be scheduled at a specific point in the menstrual cycle?
[ ] yes [ ] no
2. If so, at what point in the cycle? __________________
3. If there will be a need to enter the uterine cavity, what is the diameter of the instrument that will enter the cervical canal? _____ mm.
4. Will a tenaculum be used?
[ ] yes [ ] no
5. Could the examination or procedure itself lead to any spotting or bleeding?
[ ] yes [ ] no
6. If so, what is/are the likely source(s) of the bleeding?
[ ] vaginal wall
[ ] outside of cervix
[ ] cervical canal
[ ] uterus
7. For how long is bleeding expected to last? (For example, the scraping of a Pap smear may be followed by a day or so of spotting.) ______ days
