**Sexual Assault Protocols**

**Warm Springs Health and Wellness Center**

> The purpose of these protocols is to provide for medical professionals
> in the care of the Sexual Assault Survivor. The goal is to ensure that
> compassionate and sensitive delivery of services and care, are
> provided in a non- judgmental manner. The following protocols are
> based on current Oregon and Local Tribal Law, American College of
> Emergency Physicians recommendations for the prophylactic treatment of
> sexually transmitted diseases, pregnancy prevention and the "Best
> Practice "in the Care of the Sexual assault survivor. These Protocols
> are divided into three sections: Standards, Recommendations and
> Resources. The physical, emotional and psychological well being of the
> sexual assault survivor is given precedence over all other matters.

[STANDARDS]{.underline}

> These are the protocols that represent the basic standards in the care
> of the sexual assault survivor.

I.  ADVOCACY

    a.  The survivor is informed that they have the right to speak to a
        sexual assault advocate. If the survivor decides to speak with
        an advocate , notification may be made by law enforcement or a
        medical professional

II. LAW ENFORCEMNT NOTIFICATION

    a.  If the survivor is 17 years of younger, law enforcement must be
        notified

    b.  If the survivor is 18 years or older and is a dependent person
        or diminished mental capacity or 65 years of age or older, law
        enforcement must be notified

III. CONSENT

     a.  Informed consent for all procedures, evidence collection and
         treatments is obtained in all cases

     b.  Survivor 14 years and older may sign their consents

     c.  Survivors 13 years and younger, a parent or guardian must sign
         consent

IV. EVIDENCE

    a.  Standard Forensic Evidence Collection Kit, provided by Oregon
        State Police Crime lab, is used for evidence collection.

    b.  Standard Documentation Forms, Provided with the kit , are used
        in the evidence collection process

    c.  The evidence collection exam is done by a nurse examiner or
        physician currently licensed in their state of practice. The
        preferred examiner would be a sexual assault forensic examiner

V.  RELEASE OF INFORMATION

    a.  Release of information /documentation is not done without first
        informing the survivor of the reasons for release and obtaining
        a signed consent

VI. COST OF EVIDENCE COLLECTION

    a.  Survivors will not be charged for the cost of the forensic
        evidence exam as long as they are reporting the assault to law
        enforcement or an exam has been requested by law enforcement.

VII. TREATMENT

     a.  Every survivor will be offered prophylactic treatment for
         gonorrhea, chlamydia, trichomonas and hepatitis B if available.
         Survivors should be informed in addition, they may be at risk
         for having contracted HPV and herpes and be offered information
         about these STDs. Survivors may be offered tetanus vaccine if
         indicated.

     b.  Every survivor will be offered prophylactic treatment for
         pregnancy prevention. If the survivor declines pregnancy
         prophylaxis, obtain refusal consent.

         [RECOMMENDATIONS]{.underline}

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I.  EMERGENCY CONTRACEPTION IN THE NON-PREGNANT SURVIVOR

    A.  Pregnancy prophylaxis: all female survivors will be assessed for
        pregnancy. For survivors who have a negative pregnancy test and
        are at risk for conception from this assault, do the following:

        i.  Offer Emergency Contraception. Provide education to the
            survivor about Emergency Contraception so that she can make
            an informed choice

        ii. Obtain the survivors signed consent for emergency
            contraception

        iii. Dispense the pills to the survivor and encourage the first
             dose be taken as soon as possible

        iv. Listed below are the medications used for Emergency
            Contraception

            1.  Plan B

            2.  Preven

            3.  **Orval** (available in clinic pharmacy, 2 now 2 in 12
                hours)

            4.  Ogestrel

            5.  Alesse

            6.  Aviane

            7.  Levlite

            8.  Nordette

            9.  Levlen

            10. Levora

            11. Lo/Ovral

            12. Low-Ogestrol

            13. Triphasil

            14. Tri-levlen

            15. Trivora

            16. Orvette

                Plan B is the preferred drug as it contains no estrogen
                and side effects are greatly reduced

The treatment of choice is one dose within 72 hours after unprotected
intercourse and another dose 12 hours later. However, current research
indicates that EC remains highly effective for 120 hours (5 days) after
intercourse and survivors should be offered the choice of taking EC up
to 120 hours.

B.  **Anti-emetic medications** may be used when giving Emergency
    Contraception. Listed below are medications recommended for this
    use:

    i.  Metoclopramide 10 mg PO q 6 hours prn

    ii. Meclizine 25-50 mg PO q 6 hours

    iii. Diphenhydramine 25-50 mg PO q 6 hours

    iv. Promethizine 25 mg PO or PR q 6 hours prn

    v.  Dramamine 25-50 mg PO q 6 hours prn

**Doses of anti emetics should be altered according to the patient's
weight, age and other current medications.**

II. INFECTIOUS DISEASE PROPHYLAXIS IN THE NON-PREGNANT SURVIVOR

**Review allergies with the survivor and dispense accordingly. Do not
use Ciprofloxacin in pregnancy.**

A.  Gonorrhea Prophylaxis:

    i.  Cefixime (Suprax) 400 mg PO x 1 dose

    ii. Cefpodoxime (Vantin) 200mg PO x 1 dose

    iii. Ciprofloxacin (Cipro) 500mg PO x 1 dose

    iv. Ceftriaxone 125mg IM x 1 dose

    v.  Spectinomycin 40 mg/kg IM x 1 dose (max 2 g)

B.  Chlamydia Prophylaxis:

    i.  Azithromycin (Zithromax) 1 gram PO x 1 dose.

    ii. Doxycycline 100 mg PO BID x 7 days

**Do not use doxcycline in pregnancy**

C.  Trichomonas Prophylaxis:

    i.  Metronidazole (Flagyl) 2 grams PO x 1 dose

D.  Hepatitis B Prophylaxis:

    i.  If the survivor has never been immunized to Hepatitis B, you may
        initiate the first dose of the Hepatitis B vaccine in the
        Emergency Department.

    ii. If the survivor is unsure of their immunization status or has
        been partially immunized, draw Hepatitis B antibody titer. At
        the time of discharge provide the patient with instructions for
        appropriate follow up of titer results and completion of the
        vaccine series

E.  Tetanus Prophylaxis:

    i.  If the patient has skin abrasions of other wound and the
        immunization status is unknown or grater than 10 years, for low
        risk wound and greater or 5 years for high risk wound, give the
        dT immunization

    ii. If the survivor has never been immunized, give Tetanus Immune
        Globulin (Hypertet) 250 units IM and dT immunization. Give each
        IM injection in a different extremity. Refer the patient for
        follow up to complete the immunization series

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III. INFECTIOUS DISEASE PROPHYLAXIS IN THE PREGNANT SURVIVOR

     **Review allergies with the survivor and dispense accordingly.**

     A.  Gonorrhea Prophylaxis:

         i.  Cefixime (Suprax) 400 mg PO x 1 dose

         ii. Cefpodoxime (Vantin) 200mg PO x 1 dose

         iii. Ceftriaxone 125mg IM x 1 dose

         iv. Spectinomycin 40 mg/kg IM x 1 dose (max 2 g)

     B.  Chlamydia Prophylaxis:

         i.  Azithromycin (Zithromax) 1 gram PO x 1 dose.

     C.  Trichomonas Prophylaxis:

         i.  Metronidazole (Flagyl) 2 grams PO x 1 dose

     D.  Hepatitis B Prophylaxis:

         i.  If the survivor has never been immunized to Hepatitis B,
             you may initiate the first dose of the Hepatitis B vaccine
             in the Emergency Department.

         ii. If the survivor is unsure of their immunization status or
             has been partially immunized, draw Hepatitis B antibody
             titer. At the time of discharge provide the patient with
             instructions for appropriate follow up of titer results and
             completion of the vaccine series

     E.  Tetanus Prophylaxis:

         i.  If the patient has skin abrasions of other wound and the
             immunization status is unknown or grater than 10 years ,
             for low risk wound and greater or 5 years for high risk
             wound, give the dT immunization

         ii. If the survivor has never been immunized, give Tetanus
             Immune Globulin (Hypertet) 250 units IM and dT
             immunization. Give each IM injection in a different
             extremity. Refer the patient for follow up to complete the
             immunization series

             **RESOURCES**

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I.  FOLLOW UP

    A.  Appropriate medical follow up will be given for evaluation of
        possible sexually transmitted diseases, pregnancy and any
        physical injuries the survivor may have sustained during the
        assault.

    B.  Follow up counseling information will be provided to the
        survivor by the sexual assault advocate or the forensic medical
        examiner.

    C.  Information on area resources concerning: medical follow up,
        crisis intervention phone numbers, rape crisis centers,
        shelters, Crime Victims Compensation Program, law enforcement
        and the district attorney's office will be given to the survivor
        at the time of discharge.

        **FORM 1- PAGE 1 OF 2**

        **INFORMATION PERTAINING**

        **TO ASSAULT**

        Patient ID

<table>
<colgroup>
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 17%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="23"><p>Date of assault ______________ Approximate time of
assault _______AM PM</p>
<p>Date of exam________________ Time of Exam______________AM PM
Approximate hours since assault_____</p>
<p>City/Town/Jurisdiction of assault
_________________________________________________________________________</p>
<blockquote>
<p><span dir="rtl">ٱ</span>House / Apartment <span
dir="rtl">ٱ</span>Automobile <span dir="rtl">ٱ</span>Outdoors <span
dir="rtl">ٱ</span>Other____________ <span dir="rtl">ٱ</span>Unsure</p>
</blockquote>
<p>Agency providing
service____________________________________________________________________________________________________</p>
<p>Advocate present <span dir="rtl">ٱ</span>yes <span
dir="rtl">ٱ</span>no
Name___________________________________________________________________________________________</p>
<p>Translator used <span dir="rtl">ٱ</span>yes <span
dir="rtl">ٱ</span>no
language__________________________________________________________________________________________</p></td>
</tr>
<tr class="even">
<td colspan="23"><strong>Assailant information ( use separate sheet for
each assailant)</strong></td>
</tr>
<tr class="odd">
<td colspan="23"><p>Approximate age_____ Gender <span
dir="rtl">ٱ</span>male <span dir="rtl">ٱ</span>female Assailants
Name______________________________________________________</p>
<p>Race <span dir="rtl">ٱ</span> White (non-Hispanic) <span
dir="rtl">ٱ</span>Hispanic <span dir="rtl">ٱ</span>Black (non-Hispanic)
<span dir="rtl">ٱ</span>Native American <span
dir="rtl">ٱ</span>Asian/Pac Is</p>
<p>Distinguishing features (piercing, tattoos, etc.
)_________________________________________</p>
<p>Circumcised <span dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>
no</p>
<p>Total number of Assailants__________</p></td>
</tr>
<tr class="even">
<td colspan="23"><strong>Assailant (s) relationship to patient –
Identify with numbers</strong></td>
</tr>
<tr class="odd">
<td colspan="5"><p>Parent/Step parent</p>
<p>Spouse/ Live-in partner</p>
<p>Ex-spouse /live in partner</p>
<p>Parents live in</p>
<p>Stranger</p>
<p>Care giver</p>
<p>Sibling</p></td>
<td colspan="5"><blockquote>
<p>#male</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
</blockquote></td>
<td colspan="4"><blockquote>
<p>#female</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
</blockquote></td>
<td colspan="5"><blockquote>
<p>Boyfriend/girlfriend</p>
<p>Ex- boyfriend/girlfriend</p>
<p>Date</p>
<p>Friend</p>
<p>Other(specify)</p>
<p>__________________</p>
</blockquote></td>
<td><blockquote>
<p>#male</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
</blockquote></td>
<td colspan="3"><blockquote>
<p>#Female</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
<p>____</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="14"><strong>Acts</strong></td>
<td colspan="9"><strong>Described By the Patient</strong></td>
</tr>
<tr class="odd">
<td colspan="23">Was there penetration , however slight of :</td>
</tr>
<tr class="even">
<td colspan="2"><p><strong>Vagina?</strong></p>
<p><strong>Anus?</strong></p>
<p><strong>Mouth?</strong></p></td>
<td colspan="2"><blockquote>
<p><span dir="rtl">ٱ</span>No</p>
<p><span dir="rtl">ٱ</span>No</p>
<p><span dir="rtl">ٱ</span>No</p>
</blockquote></td>
<td colspan="4"><p><span dir="rtl">ٱ</span>Unsure</p>
<p><span dir="rtl">ٱ</span>Unsure</p>
<p><span dir="rtl">ٱ</span>Unsure</p></td>
<td colspan="4"><blockquote>
<p><span dir="rtl">ٱ</span>attempt</p>
</blockquote>
<p><span dir="rtl">ٱ</span>attempt</p>
<p><span dir="rtl">ٱ</span>attempt</p></td>
<td colspan="2"><blockquote>
<p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p>
</blockquote>
<p><span dir="rtl">ٱ</span> yes</p></td>
<td colspan="2"><blockquote>
<p><strong>BY…</strong></p>
<p><strong>BY…</strong></p>
<p><strong>BY…</strong></p>
</blockquote></td>
<td colspan="2"><blockquote>
<p><span dir="rtl">ٱ</span>penis</p>
<p><span dir="rtl">ٱ</span>penis</p>
<p><span dir="rtl">ٱ</span>penis</p>
</blockquote></td>
<td colspan="5"><blockquote>
<p><span dir="rtl">ٱ</span>finger <span dir="rtl">ٱ</span>tongue <span
dir="rtl">ٱ</span>object/other _____________</p>
<p><span dir="rtl">ٱ</span>finger <span dir="rtl">ٱ</span>tongue <span
dir="rtl">ٱ</span>object/other _____________</p>
<p><span dir="rtl">ٱ</span>finger <span dir="rtl">ٱ</span>tongue <span
dir="rtl">ٱ</span>object/other _____________</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="23"><p>During the assault , were acts performed by the
patient upon the assailant <span dir="rtl">ٱ</span>yes <span
dir="rtl">ٱ</span>no <span dir="rtl">ٱ</span>unsure</p>
<p>If yes,
specify__________________________________________________________________________________</p></td>
</tr>
<tr class="even">
<td colspan="13">Did ejaculation occur?</td>
<td colspan="10" rowspan="2"><blockquote>
<p>If externally, where?</p>
<p><span dir="rtl">ٱ</span>On the patient’s body… Where?
____________________________________<br />
<span dir="rtl">ٱ</span>On an object.</p>
<p>What object? ______________________ Where?
_______________________</p>
<p><span dir="rtl">ٱ</span>Other________________________________</p>
<p>Where? ____________________________________________</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="3"><p><strong>Vaginal?</strong></p>
<p><strong>Anally?</strong></p>
<p><strong>Orally?</strong></p>
<p><strong>Externally?</strong></p></td>
<td colspan="2"><blockquote>
<p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p>
</blockquote></td>
<td colspan="4"><blockquote>
<p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p>
</blockquote></td>
<td colspan="4"><blockquote>
<p><span dir="rtl">ٱ</span>unsure</p>
<p><span dir="rtl">ٱ</span>unsure</p>
<p><span dir="rtl">ٱ</span>unsure</p>
<p><span dir="rtl">ٱ</span>unsure</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="23"><p>Did assailant(s) use a condom) <span
dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no <span
dir="rtl">ٱ</span>unsure</p>
<p>Did assailant(s) use any substance as lubrication (saliva is
considered lubrication): <span dir="rtl">ٱ</span>yes <span
dir="rtl">ٱ</span>no <span dir="rtl">ٱ</span>unsure</p>
<p>If yes.
specify:_________________________________________________________________________________________________________</p>
<p>Did the assailant(s) kiss, lick, spit, or make other oral contact
with patient? <span dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no
<span dir="rtl">ٱ</span>unsure</p>
<p>If yes,
specify:_________________________________________________________________________________________________________</p>
<p>Did the assailant(s) touch the patient in other way? <span
dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no <span
dir="rtl">ٱ</span>unsure</p>
<p>If yes , specify
location:__________________________________________________________________________________________________</p>
<p>Any injuries to patient resulting in bleeding? <span
dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no <span
dir="rtl">ٱ</span>unsure</p>
<p>If yes
describe:__________________________________________________________________________________________________________</p>
<p>Any vomiting, urination, defecation, at the time of assault? <span
dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no <span
dir="rtl">ٱ</span>unsure</p>
<p>If yes
specify____________________________________________________________________________________________________________</p>
<p>Any lapse of consciousness? <span dir="rtl">ٱ</span>yes <span
dir="rtl">ٱ</span>no <span dir="rtl">ٱ</span>unsure</p>
<p>Any injuries to the assailant(s) resulting in bleeding? <span
dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no <span
dir="rtl">ٱ</span>unsure</p>
<p>If yes please
describe:____________________________________________________________________________________________________</p>
<p>_____________________________________________________
X________________________________________________ _____</p>
<p>PRINTED NAME OF MEDICAL PROVIDER OR NURSE EXAMINER SIGNATURE OF
MEDICAL PROVIDER OR NURSE EXAMINER DATE</p></td>
</tr>
<tr class="odd">
<td colspan="23"><p><strong>FORM 1- PAGE 2 OF 2</strong></p>
<p><strong>INFORMATION PERTAINING</strong></p>
<p><strong>TO ASSAULT</strong></p>
<p>PATIENT ID</p></td>
</tr>
<tr class="even">
<td colspan="23"><strong>WEAPON /FORCE USED</strong></td>
</tr>
<tr class="odd">
<td colspan="23"><strong>Check all that apply as per patient report
and/or physical findings</strong></td>
</tr>
<tr class="even">
<td><strong>√</strong></td>
<td colspan="5"></td>
<td colspan="17"><strong>Describe the incident and/ or body part
involved</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Verbal Threats</strong></td>
<td colspan="17"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"><strong>Strangling</strong></td>
<td colspan="17"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Bites</strong></td>
<td colspan="17"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"><strong>Hitting</strong></td>
<td colspan="17"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Burns</strong></td>
<td colspan="17"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"><strong>Gun</strong></td>
<td colspan="17"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Knife</strong></td>
<td colspan="17"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"><strong>Blunt Object</strong></td>
<td colspan="17"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Restraints</strong></td>
<td colspan="17"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"><strong>Other Weapons</strong></td>
<td colspan="17"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"><strong>Other Physical</strong></td>
<td colspan="17"></td>
</tr>
<tr class="even">
<td colspan="23"><strong>SINCE THE TIME OF THE ASSAULT HAS THE
PATIENT…</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><p><strong>Changed clothes</strong></p>
<p><strong>Brushed teeth</strong></p>
<p><strong>Bathed/showered</strong></p>
<p><strong>Washed off</strong></p></td>
<td colspan="3"><blockquote>
<p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p>
</blockquote>
<p><span dir="rtl">ٱ</span> yes</p>
<p><span dir="rtl">ٱ</span>yes</p></td>
<td colspan="4"><p><span dir="rtl">ٱ</span> no</p>
<blockquote>
<p><span dir="rtl">ٱ</span>no</p>
</blockquote>
<p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p></td>
<td colspan="4"><p><strong>Vomited</strong></p>
<p><strong>Defecated</strong></p>
<p><strong>Urinated</strong></p>
<p><strong>Used an Enema</strong></p></td>
<td colspan="2"><p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p></td>
<td><p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p></td>
<td colspan="3"><blockquote>
<p><strong>Smoked cigarettes</strong></p>
<p><strong>Eaten</strong></p>
<p><strong>Taken in Fluid</strong></p>
</blockquote>
<p><strong>Douched</strong></p></td>
<td><p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p>
<p><span dir="rtl">ٱ</span>yes</p></td>
<td><p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p>
<p><span dir="rtl">ٱ</span>no</p></td>
</tr>
<tr class="even">
<td colspan="23"><strong>PERTINENT RECENT HEALTH HISTORY</strong></td>
</tr>
<tr class="odd">
<td colspan="23"><p>Has the patient undergone recent medical, surgical
or gynecological procedures or treatments which may affect physical
findings or evidence collection? <span dir="rtl">ٱ</span>yes <span
dir="rtl">ٱ</span>no</p>
<p>If yes
describe______________________________________________________________________________________________</p>
<p>Is the patient pregnant? <span dir="rtl">ٱ</span>yes <span
dir="rtl">ٱ</span>no EDC _________ EGA________ LMP_________
FHT_______</p>
<p>Patient menstruating at the time of assault? <span
dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no Currently <span
dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no</p>
<p>Patients tampon or sanitary napkin to be included in kit <span
dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no</p>
<p>When was the last time the patient had consensual sexual
intercourse?_________________________________________________</p>
<p>Is the patient using any type of contraception? <span
dir="rtl">ٱ</span>yes <span dir="rtl">ٱ</span>no If yes specify
_____________________________________________</p>
<p>________________________________________________
____________________________________________ _________</p>
<p>PRINTED NAME OF MEDICAL PROVIDER OR NURSE EXAMINER SIGNATURE OF
MEDICAL PROVIDER OR NURSE EXAMINER DATE</p></td>
</tr>
</tbody>
</table>

+-----------------------------------------------------------------------+
| **FORM 2**                                                            |
|                                                                       |
| **PATIENTS REPORT**                                                   |
|                                                                       |
| **OF INCIDENT**                                                       |
|                                                                       |
| PATIENT ID                                                            |
+-----------------------------------------------------------------------+
| **Note this form is to be completed by [one]{.underline} examiner**.  |
|                                                                       |
| -   This report is not an exhaustive account of every detail of the   |
|     sexual assault but a brief description                            |
|                                                                       |
| -   Use the patients own words, in quotes whenever possible. If you   |
|     are not using the patients own words, be careful not to use       |
|     quotes.                                                           |
|                                                                       |
| -   When speaking with the patient, ensure that he/she understands    |
|     your questions and your vocabulary. Record in the patients own    |
|     terminology                                                       |
|                                                                       |
| -   Do not include personal opinion or conjecture                     |
|                                                                       |
| Include only information that directly relates to this assault.       |
| (description of surroundings, threats, force , weapons, trauma and    |
| sexual acts                                                           |
+-----------------------------------------------------------------------+
| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\                                                           |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\                                                           |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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|                                                                       |
| \_\_\_\_\                                                             |
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|                                                                       |
| \_\_\_\_\                                                             |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
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|                                                                       |
| \_\_\_\_\                                                             |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
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|                                                                       |
| \_\_\_\_\_\                                                           |
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| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
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|                                                                       |
| \_\_\_\_\_\                                                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
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|                                                                       |
| \_\_\_\_\_\                                                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
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|                                                                       |
| \_\_\_\_\_\                                                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| PRINTED NAME OF MEDICAL PROVIDER OR NURSE EXAMINER SIGNATURE OF       |
| MEDICAL PROVIDER OR NURSE DATE                                        |
+-----------------------------------------------------------------------+

**FORM 3**

**PHYSICAL APPEARANCE**

**WOUND DOCUMENTATION**

PATIENT ID

+-----------------------------------------------------------------------+
| **Record the patient's general physical appearance and demeanor**     |
+-----------------------------------------------------------------------+
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| Patient's Race [ٱ]{dir="rtl"}White(non-Hispanic)                      |
| [ٱ]{dir="rtl"}Hispanic [ٱ]{dir="rtl"}Black(non-Hispanic)              |
| [ٱ]{dir="rtl"}Native American [ٱ]{dir="rtl"}Asian/Pac Is              |
| [ٱ]{dir="rtl"}other [ٱ]{dir="rtl"}unsure                              |
+-----------------------------------------------------------------------+
| Record injuries and findings on the diagram. Further documentation    |
| may be noted in other areas of the medical report. Document size of   |
| wounds                                                                |
|                                                                       |
| **Key:** A- Abrasion B- Bite C-Contusion D- Deformity E- Erythema L-  |
| Laceration P-Pain S- Swelling T- Tenderness                           |
+-----------------------------------------------------------------------+
| ![](media/image1.png){width="2.7956692913385828in"                    |
| height="1                                                             |
| .5070866141732284in"}![](media/image2.wmf){width="4.19251968503937in" |
| height="3.                                                            |
| 1118110236220473in"}![](media/image3.png){width="5.374409448818898in" |
| height=                                                               |
| "4.625196850393701in"}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                      |
|                                                                       |
| PRINTED NAME OF MEDICAL PROVIDER OR NURSE EXAMINER SIGNATURE OF       |
| MEDICAL PROVIDER OR NURSE EXAMINER DATE                               |
+-----------------------------------------------------------------------+

**FORM 4-MALE**

**PHYSICAL EXAMINATION**

PATIENT ID

+------+---+---+---+---+---+-------------------------------------------------+
| **   |   |   |   |   |   |                                                 |
| MALE |   |   |   |   |   |                                                 |
| GEN  |   |   |   |   |   |                                                 |
| ITAL |   |   |   |   |   |                                                 |
| ASSE |   |   |   |   |   |                                                 |
| SSME |   |   |   |   |   |                                                 |
| NT** |   |   |   |   |   |                                                 |
+------+---+---+---+---+---+-------------------------------------------------+
| MALE | > |   | N |   | > | Describe                                        |
|      |   |   | o |   |   |                                                 |
|      | I |   | i |   | S |                                                 |
|      | n |   | n |   | w |                                                 |
|      | j |   | j |   | a |                                                 |
|      | u |   | u |   | b |                                                 |
|      | r |   | r |   |   |                                                 |
|      | y |   | y |   |   |                                                 |
+------+---+---+---+---+---+-------------------------------------------------+
| P    | [ |   | [ |   | [ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
| enis | ٱ |   | ٱ |   | ٱ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | ] |   | ] |   | ] | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| Me   | { |   | { |   | { | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| atus | d |   | d |   | d |                                                 |
|      | i |   | i |   | i | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
| Scr  | r |   | r |   | r | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| otum | = |   | = |   | = | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|      | " |   | " |   | " | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Anus | r |   | r |   | r |                                                 |
|      | t |   | t |   | t | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
| Butt | l |   | l |   | l | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| ocks | " |   | " |   | " | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|      | } |   | } |   | } | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Peri |   |   |   |   |   |                                                 |
| anal | [ |   | [ |   | [ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
| Area | ٱ |   | ٱ |   | ٱ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | ] |   | ] |   | ] | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| Peri | { |   | { |   | { | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| neal | d |   | d |   | d |                                                 |
| Area | i |   | i |   | i | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
|      | r |   | r |   | r | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | = |   | = |   | = | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|      | " |   | " |   | " | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | r |   | r |   | r |                                                 |
|      | t |   | t |   | t | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
|      | l |   | l |   | l | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | " |   | " |   | " | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|      | } |   | } |   | } | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      |   |   |   |   |   |                                                 |
|      | [ |   | [ |   | [ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
|      | ٱ |   | ٱ |   | ٱ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | ] |   | ] |   | ] | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|      | { |   | { |   | { | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | d |   | d |   | d |                                                 |
|      | i |   | i |   | i | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
|      | r |   | r |   | r | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | = |   | = |   | = | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|      | " |   | " |   | " | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | r |   | r |   | r |                                                 |
|      | t |   | t |   | t | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\                 |
|      | l |   | l |   | l | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      | " |   | " |   | " | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|      | } |   | } |   | } | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      |   |   |   |   |   |                                                 |
|      | [ |   | [ |   | [ |                                                 |
|      | ٱ |   | ٱ |   | ٱ |                                                 |
|      | ] |   | ] |   | ] |                                                 |
|      | { |   | { |   | { |                                                 |
|      | d |   | d |   | d |                                                 |
|      | i |   | i |   | i |                                                 |
|      | r |   | r |   | r |                                                 |
|      | = |   | = |   | = |                                                 |
|      | " |   | " |   | " |                                                 |
|      | r |   | r |   | r |                                                 |
|      | t |   | t |   | t |                                                 |
|      | l |   | l |   | l |                                                 |
|      | " |   | " |   | " |                                                 |
|      | } |   | } |   | } |                                                 |
|      |   |   |   |   |   |                                                 |
|      | [ |   | [ |   | [ |                                                 |
|      | ٱ |   | ٱ |   | ٱ |                                                 |
|      | ] |   | ] |   | ] |                                                 |
|      | { |   | { |   | { |                                                 |
|      | d |   | d |   | d |                                                 |
|      | i |   | i |   | i |                                                 |
|      | r |   | r |   | r |                                                 |
|      | = |   | = |   | = |                                                 |
|      | " |   | " |   | " |                                                 |
|      | r |   | r |   | r |                                                 |
|      | t |   | t |   | t |                                                 |
|      | l |   | l |   | l |                                                 |
|      | " |   | " |   | " |                                                 |
|      | } |   | } |   | } |                                                 |
|      |   |   |   |   |   |                                                 |
|      | [ |   | [ |   | [ |                                                 |
|      | ٱ |   | ٱ |   | ٱ |                                                 |
|      | ] |   | ] |   | ] |                                                 |
|      | { |   | { |   | { |                                                 |
|      | d |   | d |   | d |                                                 |
|      | i |   | i |   | i |                                                 |
|      | r |   | r |   | r |                                                 |
|      | = |   | = |   | = |                                                 |
|      | " |   | " |   | " |                                                 |
|      | r |   | r |   | r |                                                 |
|      | t |   | t |   | t |                                                 |
|      | l |   | l |   | l |                                                 |
|      | " |   | " |   | " |                                                 |
|      | } |   | } |   | } |                                                 |
|      |   |   |   |   |   |                                                 |
|      | [ |   | [ |   | [ |                                                 |
|      | ٱ |   | ٱ |   | ٱ |                                                 |
|      | ] |   | ] |   | ] |                                                 |
|      | { |   | { |   | { |                                                 |
|      | d |   | d |   | d |                                                 |
|      | i |   | i |   | i |                                                 |
|      | r |   | r |   | r |                                                 |
|      | = |   | = |   | = |                                                 |
|      | " |   | " |   | " |                                                 |
|      | r |   | r |   | r |                                                 |
|      | t |   | t |   | t |                                                 |
|      | l |   | l |   | l |                                                 |
|      | " |   | " |   | " |                                                 |
|      | } |   | } |   | } |                                                 |
|      |   |   |   |   |   |                                                 |
|      | [ |   | [ |   | [ |                                                 |
|      | ٱ |   | ٱ |   | ٱ |                                                 |
|      | ] |   | ] |   | ] |                                                 |
|      | { |   | { |   | { |                                                 |
|      | d |   | d |   | d |                                                 |
|      | i |   | i |   | i |                                                 |
|      | r |   | r |   | r |                                                 |
|      | = |   | = |   | = |                                                 |
|      | " |   | " |   | " |                                                 |
|      | r |   | r |   | r |                                                 |
|      | t |   | t |   | t |                                                 |
|      | l |   | l |   | l |                                                 |
|      | " |   | " |   | " |                                                 |
|      | } |   | } |   | } |                                                 |
+------+---+---+---+---+---+-------------------------------------------------+
| Di   |   | > |   | > |   | > Describe\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_      |
| rect |   |   |   |   |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| V    |   | [ |   | [ |   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| isua |   | ٱ |   | ٱ |   | >                                               |
| liza |   | ] |   | ] |   | > Describe                                      |
| tion |   | { |   | { |   | >                                               |
|      |   | d |   | d |   |  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Di   |   | i |   | i |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| scha |   | r |   | r |   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| rge: |   | = |   | = |   | >                                               |
|      |   | " |   | " |   | > Describe                                      |
| Circ |   | r |   | r |   | > \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                |
| umci |   | t |   | t |   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| sed: |   | l |   | l |   | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|      |   | " |   | " |   | >                                               |
| Anos |   | } |   | } |   | > [ٱ]{dir="rtl"}not done                        |
| cope |   | Y |   | N |   |                                                 |
|      |   | e |   | o |   |                                                 |
| G    |   | s |   | > |   |                                                 |
| uiac |   | > |   | > |   |                                                 |
|      |   | > |   |   |   |                                                 |
|      |   |   |   | [ |   |                                                 |
|      |   | [ |   | ٱ |   |                                                 |
|      |   | ٱ |   | ] |   |                                                 |
|      |   | ] |   | { |   |                                                 |
|      |   | { |   | d |   |                                                 |
|      |   | d |   | i |   |                                                 |
|      |   | i |   | r |   |                                                 |
|      |   | r |   | = |   |                                                 |
|      |   | = |   | " |   |                                                 |
|      |   | " |   | r |   |                                                 |
|      |   | r |   | t |   |                                                 |
|      |   | t |   | l |   |                                                 |
|      |   | l |   | " |   |                                                 |
|      |   | " |   | } |   |                                                 |
|      |   | } |   | N |   |                                                 |
|      |   | Y |   | o |   |                                                 |
|      |   | e |   | > |   |                                                 |
|      |   | s |   | > |   |                                                 |
|      |   | > |   |   |   |                                                 |
|      |   | > |   | [ |   |                                                 |
|      |   |   |   | ٱ |   |                                                 |
|      |   | [ |   | ] |   |                                                 |
|      |   | ٱ |   | { |   |                                                 |
|      |   | ] |   | d |   |                                                 |
|      |   | { |   | i |   |                                                 |
|      |   | d |   | r |   |                                                 |
|      |   | i |   | = |   |                                                 |
|      |   | r |   | " |   |                                                 |
|      |   | = |   | r |   |                                                 |
|      |   | " |   | t |   |                                                 |
|      |   | r |   | l |   |                                                 |
|      |   | t |   | " |   |                                                 |
|      |   | l |   | } |   |                                                 |
|      |   | " |   | N |   |                                                 |
|      |   | } |   | o |   |                                                 |
|      |   | Y |   | > |   |                                                 |
|      |   | e |   | > |   |                                                 |
|      |   | s |   |   |   |                                                 |
|      |   | > |   | [ |   |                                                 |
|      |   | > |   | ٱ |   |                                                 |
|      |   |   |   | ] |   |                                                 |
|      |   | [ |   | { |   |                                                 |
|      |   | ٱ |   | d |   |                                                 |
|      |   | ] |   | i |   |                                                 |
|      |   | { |   | r |   |                                                 |
|      |   | d |   | = |   |                                                 |
|      |   | i |   | " |   |                                                 |
|      |   | r |   | r |   |                                                 |
|      |   | = |   | t |   |                                                 |
|      |   | " |   | l |   |                                                 |
|      |   | r |   | " |   |                                                 |
|      |   | t |   | } |   |                                                 |
|      |   | l |   | N |   |                                                 |
|      |   | " |   | o |   |                                                 |
|      |   | } |   | > |   |                                                 |
|      |   | Y |   | > |   |                                                 |
|      |   | e |   |   |   |                                                 |
|      |   | s |   | [ |   |                                                 |
|      |   | > |   | ٱ |   |                                                 |
|      |   | > |   | ] |   |                                                 |
|      |   |   |   | { |   |                                                 |
|      |   | [ |   | d |   |                                                 |
|      |   | ٱ |   | i |   |                                                 |
|      |   | ] |   | r |   |                                                 |
|      |   | { |   | = |   |                                                 |
|      |   | d |   | " |   |                                                 |
|      |   | i |   | r |   |                                                 |
|      |   | r |   | t |   |                                                 |
|      |   | = |   | l |   |                                                 |
|      |   | " |   | " |   |                                                 |
|      |   | r |   | } |   |                                                 |
|      |   | t |   | n |   |                                                 |
|      |   | l |   | e |   |                                                 |
|      |   | " |   | g |   |                                                 |
|      |   | } |   | a |   |                                                 |
|      |   | p |   | t |   |                                                 |
|      |   | o |   | i |   |                                                 |
|      |   | s |   | v |   |                                                 |
|      |   | i |   | e |   |                                                 |
|      |   | t |   |   |   |                                                 |
|      |   | i |   |   |   |                                                 |
|      |   | v |   |   |   |                                                 |
|      |   | e |   |   |   |                                                 |
+------+---+---+---+---+---+-------------------------------------------------+
| Dia  |   |   |   |   |   |                                                 |
| gram |   |   |   |   |   |                                                 |
| Key: |   |   |   |   |   |                                                 |
|      |   |   |   |   |   |                                                 |
| **Ke |   |   |   |   |   |                                                 |
| y:** |   |   |   |   |   |                                                 |
| A-   |   |   |   |   |   |                                                 |
| Abra |   |   |   |   |   |                                                 |
| sion |   |   |   |   |   |                                                 |
| B-   |   |   |   |   |   |                                                 |
| Bite |   |   |   |   |   |                                                 |
| C-C  |   |   |   |   |   |                                                 |
| ontu |   |   |   |   |   |                                                 |
| sion |   |   |   |   |   |                                                 |
| D-   |   |   |   |   |   |                                                 |
| D    |   |   |   |   |   |                                                 |
| efor |   |   |   |   |   |                                                 |
| mity |   |   |   |   |   |                                                 |
| E-   |   |   |   |   |   |                                                 |
| Eryt |   |   |   |   |   |                                                 |
| hema |   |   |   |   |   |                                                 |
| L-   |   |   |   |   |   |                                                 |
| La   |   |   |   |   |   |                                                 |
| cera |   |   |   |   |   |                                                 |
| tion |   |   |   |   |   |                                                 |
| P-   |   |   |   |   |   |                                                 |
| Pain |   |   |   |   |   |                                                 |
| S-   |   |   |   |   |   |                                                 |
| Swel |   |   |   |   |   |                                                 |
| ling |   |   |   |   |   |                                                 |
| T-   |   |   |   |   |   |                                                 |
| Te   |   |   |   |   |   |                                                 |
| nder |   |   |   |   |   |                                                 |
| ness |   |   |   |   |   |                                                 |
+------+---+---+---+---+---+-------------------------------------------------+
| !    |   |   |   |   |   |                                                 |
| [](m |   |   |   |   |   |                                                 |
| edia |   |   |   |   |   |                                                 |
| /ima |   |   |   |   |   |                                                 |
| ge5. |   |   |   |   |   |                                                 |
| wmf) |   |   |   |   |   |                                                 |
| {wid |   |   |   |   |   |                                                 |
| th=" |   |   |   |   |   |                                                 |
| 5.99 |   |   |   |   |   |                                                 |
| 7916 |   |   |   |   |   |                                                 |
| 6666 |   |   |   |   |   |                                                 |
| 6666 |   |   |   |   |   |                                                 |
| 7in" |   |   |   |   |   |                                                 |
| he   |   |   |   |   |   |                                                 |
| ight |   |   |   |   |   |                                                 |
| ="2. |   |   |   |   |   |                                                 |
| 6972 |   |   |   |   |   |                                                 |
| 2222 |   |   |   |   |   |                                                 |
| 2222 |   |   |   |   |   |                                                 |
| 2224 |   |   |   |   |   |                                                 |
| in"} |   |   |   |   |   |                                                 |
+------+---+---+---+---+---+-------------------------------------------------+
| \_   |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
|      |   |   |   |   |   |                                                 |
| PRI  |   |   |   |   |   |                                                 |
| NTED |   |   |   |   |   |                                                 |
| NAME |   |   |   |   |   |                                                 |
| OF   |   |   |   |   |   |                                                 |
| MED  |   |   |   |   |   |                                                 |
| ICAL |   |   |   |   |   |                                                 |
| PROV |   |   |   |   |   |                                                 |
| IDER |   |   |   |   |   |                                                 |
| OR   |   |   |   |   |   |                                                 |
| N    |   |   |   |   |   |                                                 |
| URSE |   |   |   |   |   |                                                 |
| EXAM |   |   |   |   |   |                                                 |
| INER |   |   |   |   |   |                                                 |
| S    |   |   |   |   |   |                                                 |
| IGNA |   |   |   |   |   |                                                 |
| TURE |   |   |   |   |   |                                                 |
| OF   |   |   |   |   |   |                                                 |
| MED  |   |   |   |   |   |                                                 |
| ICAL |   |   |   |   |   |                                                 |
| PROV |   |   |   |   |   |                                                 |
| IDER |   |   |   |   |   |                                                 |
| OR   |   |   |   |   |   |                                                 |
| N    |   |   |   |   |   |                                                 |
| URSE |   |   |   |   |   |                                                 |
| EXAM |   |   |   |   |   |                                                 |
| INER |   |   |   |   |   |                                                 |
| DATE |   |   |   |   |   |                                                 |
|      |   |   |   |   |   |                                                 |
| \_   |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
| \_\_ |   |   |   |   |   |                                                 |
|      |   |   |   |   |   |                                                 |
| PRI  |   |   |   |   |   |                                                 |
| NTED |   |   |   |   |   |                                                 |
| NAME |   |   |   |   |   |                                                 |
| OF   |   |   |   |   |   |                                                 |
| MED  |   |   |   |   |   |                                                 |
| ICAL |   |   |   |   |   |                                                 |
| PROV |   |   |   |   |   |                                                 |
| IDER |   |   |   |   |   |                                                 |
| OR   |   |   |   |   |   |                                                 |
| N    |   |   |   |   |   |                                                 |
| URSE |   |   |   |   |   |                                                 |
| EXAM |   |   |   |   |   |                                                 |
| INER |   |   |   |   |   |                                                 |
| S    |   |   |   |   |   |                                                 |
| IGNA |   |   |   |   |   |                                                 |
| TURE |   |   |   |   |   |                                                 |
| OF   |   |   |   |   |   |                                                 |
| MED  |   |   |   |   |   |                                                 |
| ICAL |   |   |   |   |   |                                                 |
| PROV |   |   |   |   |   |                                                 |
| IDER |   |   |   |   |   |                                                 |
| OR   |   |   |   |   |   |                                                 |
| N    |   |   |   |   |   |                                                 |
| URSE |   |   |   |   |   |                                                 |
| EXAM |   |   |   |   |   |                                                 |
| INER |   |   |   |   |   |                                                 |
| DATE |   |   |   |   |   |                                                 |
+------+---+---+---+---+---+-------------------------------------------------+

**FORM 4 FEMALE**

**PHYSICAL EXAMINATION**

PATIENT ID

+--------+---+----+---+----+---+----+-----------------------------------------+
| **     |   |    |   |    |   |    |                                         |
| FEMALE |   |    |   |    |   |    |                                         |
| G      |   |    |   |    |   |    |                                         |
| ENITAL |   |    |   |    |   |    |                                         |
| ASSESS |   |    |   |    |   |    |                                         |
| MENT** |   |    |   |    |   |    |                                         |
+--------+---+----+---+----+---+----+-----------------------------------------+
| FEMALE | > |    |   | N  |   | Sw | Describe                                |
|        |   |    |   | on |   | ab |                                         |
| Labia  | I |    |   | in |   |    | \_\_\_\_\_\_\_\                         |
| majora | n |    |   | ju |   | >  | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | j |    |   | ry |   | [ٱ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| Cl     | u |    |   |    |   | ]{ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| itoris | r |    |   | >  |   | di |                                         |
|        | y |    |   | [ٱ |   | r= | \_\_\_\_\_\_\_\                         |
| Periur | > |    |   | ]{ |   | "r | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| ethral | > |    |   | di |   | tl | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| tissue |   |    |   | r= |   | "} | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | [ |    |   | "r |   | >  |                                         |
| Ves    | ٱ |    |   | tl |   | >  | \_\_\_\_\_\_\_\                         |
| tibule | ] |    |   | "} |   | [ٱ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | { |    |   | >  |   | ]{ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| Vagina | d |    |   | >  |   | di | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | i |    |   | [ٱ |   | r= |                                         |
| Hymen  | r |    |   | ]{ |   | "r | \_\_\_\_\_\_\_\                         |
|        | = |    |   | di |   | tl | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Pos    | " |    |   | r= |   | "} | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| terior | r |    |   | "r |   | >  | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| For    | t |    |   | tl |   | >  |                                         |
| chette | l |    |   | "} |   | [ٱ | \_\_\_\_\_\_\_\                         |
|        | " |    |   | >  |   | ]{ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Fossa  | } |    |   | >  |   | di | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| Navic  | > |    |   | [ٱ |   | r= | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| ularis | > |    |   | ]{ |   | "r |                                         |
|        |   |    |   | di |   | tl | \_\_\_\_\_\_\_\                         |
| Cervix | [ |    |   | r= |   | "} | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | ٱ |    |   | "r |   | >  | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| Bu     | ] |    |   | tl |   | >  | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| ttocks | { |    |   | "} |   | [ٱ |                                         |
|        | d |    |   | >  |   | ]{ | \_\_\_\_\_\_\_\                         |
| Pe     | i |    |   | >  |   | di | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| rianal | r |    |   | [ٱ |   | r= | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| Area   | = |    |   | ]{ |   | "r | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | " |    |   | di |   | tl |                                         |
| Anus   | r |    |   | r= |   | "} | \_\_\_\_\_\_\_\                         |
|        | t |    |   | "r |   | >  | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Pe     | l |    |   | tl |   | >  | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| rineal | " |    |   | "} |   | [ٱ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Area   | } |    |   | >  |   | ]{ |                                         |
|        | > |    |   | >  |   | di | \_\_\_\_\_\_\_\                         |
| Other  | > |    |   | [ٱ |   | r= | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        |   |    |   | ]{ |   | "r | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
| Guiac  | [ |    |   | di |   | tl | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | ٱ |    |   | r= |   | "} |                                         |
|        | ] |    |   | "r |   | >  | \_\_\_\_\_\_\_\                         |
|        | { |    |   | tl |   | >  | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | d |    |   | "} |   | [ٱ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|        | i |    |   | >  |   | ]{ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | r |    |   | >  |   | di |                                         |
|        | = |    |   | [ٱ |   | r= | \_\_\_\_\_\_\_\                         |
|        | " |    |   | ]{ |   | "r | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | r |    |   | di |   | tl | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
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|        | l |    |   | "r |   | >  |                                         |
|        | " |    |   | tl |   | >  | \_\_\_\_\_\_\_\                         |
|        | } |    |   | "} |   | [ٱ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | > |    |   | >  |   | ]{ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|        | > |    |   | >  |   | di | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        |   |    |   | [ٱ |   | r= |                                         |
|        | [ |    |   | ]{ |   | "r | \_\_\_\_\_\_\_\                         |
|        | ٱ |    |   | di |   | tl | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | ] |    |   | r= |   | "} | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|        | { |    |   | "r |   | >  | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | d |    |   | tl |   | >  |                                         |
|        | i |    |   | "} |   | [ٱ | \_\_\_\_\_\_\_\                         |
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|        | " |    |   | [ٱ |   | r= | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|        | r |    |   | ]{ |   | "r |                                         |
|        | t |    |   | di |   | tl | \_\_\_\_\_\_\_\                         |
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|        | > |    |   |    |   |    |                                         |
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|        |   |    |   |    |   |    |                                         |
|        | [ |    |   |    |   |    |                                         |
|        | ٱ |    |   |    |   |    |                                         |
|        | ] |    |   |    |   |    |                                         |
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|        | i |    |   |    |   |    |                                         |
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|        | = |    |   |    |   |    |                                         |
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|        | r |    |   |    |   |    |                                         |
|        | t |    |   |    |   |    |                                         |
|        | l |    |   |    |   |    |                                         |
|        | " |    |   |    |   |    |                                         |
|        | } |    |   |    |   |    |                                         |
|        | p |    |   |    |   |    |                                         |
|        | o |    |   |    |   |    |                                         |
|        | s |    |   |    |   |    |                                         |
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|        | v |    |   |    |   |    |                                         |
|        | e |    |   |    |   |    |                                         |
+--------+---+----+---+----+---+----+-----------------------------------------+
| **EXAM |   |    |   |    |   |    |                                         |
| I      |   |    |   |    |   |    |                                         |
| NFORMA |   |    |   |    |   |    |                                         |
| TION** |   |    |   |    |   |    |                                         |
+--------+---+----+---+----+---+----+-----------------------------------------+
| Direct |   | >  | [ |    |   |    |                                         |
| V      |   |  [ | ٱ |    |   |    |                                         |
| isuali |   | ٱ] | ] |    |   |    |                                         |
| zation |   | {d | { |    |   |    |                                         |
|        |   | ir | d |    |   |    |                                         |
| Sp     |   | =" | i |    |   |    |                                         |
| eculum |   | rt | r |    |   |    |                                         |
| Exam   |   | l" | = |    |   |    |                                         |
|        |   | }Y | " |    |   |    |                                         |
| Colp   |   | es | r |    |   |    |                                         |
| oscope |   | >  | t |    |   |    |                                         |
| Exam   |   | >  | l |    |   |    |                                         |
|        |   |  [ | " |    |   |    |                                         |
| An     |   | ٱ] | } |    |   |    |                                         |
| oscope |   | {d | N |    |   |    |                                         |
|        |   | ir | o |    |   |    |                                         |
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|        |   | }Y | ] |    |   |    |                                         |
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|        |   |    | d |    |   |    |                                         |
|        |   |    | i |    |   |    |                                         |
|        |   |    | r |    |   |    |                                         |
|        |   |    | = |    |   |    |                                         |
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|        |   |    | r |    |   |    |                                         |
|        |   |    | t |    |   |    |                                         |
|        |   |    | l |    |   |    |                                         |
|        |   |    | " |    |   |    |                                         |
|        |   |    | } |    |   |    |                                         |
|        |   |    | N |    |   |    |                                         |
|        |   |    | o |    |   |    |                                         |
+--------+---+----+---+----+---+----+-----------------------------------------+
| !      |   |    |   |    |   |    |                                         |
| [](med |   |    |   |    |   |    |                                         |
| ia/ima |   |    |   |    |   |    |                                         |
| ge6.pn |   |    |   |    |   |    |                                         |
| g){wid |   |    |   |    |   |    |                                         |
| th="6. |   |    |   |    |   |    |                                         |
| 097916 |   |    |   |    |   |    |                                         |
| 666666 |   |    |   |    |   |    |                                         |
| 666in" |   |    |   |    |   |    |                                         |
| heigh  |   |    |   |    |   |    |                                         |
| t="3.2 |   |    |   |    |   |    |                                         |
| 513888 |   |    |   |    |   |    |                                         |
| 888888 |   |    |   |    |   |    |                                         |
| 89in"} |   |    |   |    |   |    |                                         |
+--------+---+----+---+----+---+----+-----------------------------------------+
| \_\_   |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_   |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
|        |   |    |   |    |   |    |                                         |
| P      |   |    |   |    |   |    |                                         |
| RINTED |   |    |   |    |   |    |                                         |
| NAME   |   |    |   |    |   |    |                                         |
| OF     |   |    |   |    |   |    |                                         |
| M      |   |    |   |    |   |    |                                         |
| EDICAL |   |    |   |    |   |    |                                         |
| PR     |   |    |   |    |   |    |                                         |
| OVIDER |   |    |   |    |   |    |                                         |
| OR     |   |    |   |    |   |    |                                         |
| NURSE  |   |    |   |    |   |    |                                         |
| EX     |   |    |   |    |   |    |                                         |
| AMINER |   |    |   |    |   |    |                                         |
| SIG    |   |    |   |    |   |    |                                         |
| NATURE |   |    |   |    |   |    |                                         |
| OF     |   |    |   |    |   |    |                                         |
| M      |   |    |   |    |   |    |                                         |
| EDICAL |   |    |   |    |   |    |                                         |
| PR     |   |    |   |    |   |    |                                         |
| OVIDER |   |    |   |    |   |    |                                         |
| OR     |   |    |   |    |   |    |                                         |
| NURSE  |   |    |   |    |   |    |                                         |
| EX     |   |    |   |    |   |    |                                         |
| AMINER |   |    |   |    |   |    |                                         |
| DATE   |   |    |   |    |   |    |                                         |
|        |   |    |   |    |   |    |                                         |
| \_\_   |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_   |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
| \_\_\_ |   |    |   |    |   |    |                                         |
|        |   |    |   |    |   |    |                                         |
| P      |   |    |   |    |   |    |                                         |
| RINTED |   |    |   |    |   |    |                                         |
| NAME   |   |    |   |    |   |    |                                         |
| OF     |   |    |   |    |   |    |                                         |
| M      |   |    |   |    |   |    |                                         |
| EDICAL |   |    |   |    |   |    |                                         |
| PR     |   |    |   |    |   |    |                                         |
| OVIDER |   |    |   |    |   |    |                                         |
| OR     |   |    |   |    |   |    |                                         |
| NURSE  |   |    |   |    |   |    |                                         |
| EX     |   |    |   |    |   |    |                                         |
| AMINER |   |    |   |    |   |    |                                         |
| SIG    |   |    |   |    |   |    |                                         |
| NATURE |   |    |   |    |   |    |                                         |
| OF     |   |    |   |    |   |    |                                         |
| M      |   |    |   |    |   |    |                                         |
| EDICAL |   |    |   |    |   |    |                                         |
| PR     |   |    |   |    |   |    |                                         |
| OVIDER |   |    |   |    |   |    |                                         |
| OR     |   |    |   |    |   |    |                                         |
| NURSE  |   |    |   |    |   |    |                                         |
| EX     |   |    |   |    |   |    |                                         |
| AMINER |   |    |   |    |   |    |                                         |
| DATE   |   |    |   |    |   |    |                                         |
+--------+---+----+---+----+---+----+-----------------------------------------+

**FORM 5**

**TREATMENT**

**AND DISCHARGE**

PATIENT ID

+-----------+---+----+----+------+--------------------------------------+
| **LAB     |   |    |    |      |                                      |
| SPECIMENS |   |    |    |      |                                      |
| OBTAIND   |   |    |    |      |                                      |
| FOR       |   |    |    |      |                                      |
| E         |   |    |    |      |                                      |
| VALUATION |   |    |    |      |                                      |
| BY        |   |    |    |      |                                      |
| MEDICAL   |   |    |    |      |                                      |
| F         |   |    |    |      |                                      |
| ACILITY** |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| cHE       | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
| **Check   | [ |    |    |      |                                      |
| all that  | ٱ |    |    |      |                                      |
| apply:**  | ] |    |    |      |                                      |
|           | { |    |    |      |                                      |
|           | d |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | = |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | } |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | H |    |    |      |                                      |
|           | C |    |    |      |                                      |
|           | G |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | [ |    |    |      |                                      |
|           | ٱ |    |    |      |                                      |
|           | ] |    |    |      |                                      |
|           | { |    |    |      |                                      |
|           | d |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | = |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | } |    |    |      |                                      |
|           | u |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | n |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | [ |    |    |      |                                      |
|           | ٱ |    |    |      |                                      |
|           | ] |    |    |      |                                      |
|           | { |    |    |      |                                      |
|           | d |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | = |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | } |    |    |      |                                      |
|           | s |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | u |    |    |      |                                      |
|           | m |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | s |    |    |      |                                      |
|           | u |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | s |    |    |      |                                      |
|           | : |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | [ |    |    |      |                                      |
|           | ٱ |    |    |      |                                      |
|           | ] |    |    |      |                                      |
|           | { |    |    |      |                                      |
|           | d |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | = |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | } |    |    |      |                                      |
|           | p |    |    |      |                                      |
|           | o |    |    |      |                                      |
|           | s |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | v |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | [ |    |    |      |                                      |
|           | ٱ |    |    |      |                                      |
|           | ] |    |    |      |                                      |
|           | { |    |    |      |                                      |
|           | d |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | = |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | } |    |    |      |                                      |
|           | n |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | g |    |    |      |                                      |
|           | a |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | v |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | [ |    |    |      |                                      |
|           | ٱ |    |    |      |                                      |
|           | ] |    |    |      |                                      |
|           | { |    |    |      |                                      |
|           | d |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | = |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | } |    |    |      |                                      |
|           | H |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | p |    |    |      |                                      |
|           | a |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | s |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | B |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | [ |    |    |      |                                      |
|           | ٱ |    |    |      |                                      |
|           | ] |    |    |      |                                      |
|           | { |    |    |      |                                      |
|           | d |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | = |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | } |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | H |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | p |    |    |      |                                      |
|           | a |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | s |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | B |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | m |    |    |      |                                      |
|           | m |    |    |      |                                      |
|           | u |    |    |      |                                      |
|           | n |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | y |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | [ |    |    |      |                                      |
|           | ٱ |    |    |      |                                      |
|           | ] |    |    |      |                                      |
|           | { |    |    |      |                                      |
|           | d |    |    |      |                                      |
|           | i |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | = |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | " |    |    |      |                                      |
|           | } |    |    |      |                                      |
|           | O |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | h |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | r |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | a |    |    |      |                                      |
|           | b |    |    |      |                                      |
|           | s |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | : |    |    |      |                                      |
|           | > |    |    |      |                                      |
|           |   |    |    |      |                                      |
|           | R |    |    |      |                                      |
|           | e |    |    |      |                                      |
|           | s |    |    |      |                                      |
|           | u |    |    |      |                                      |
|           | l |    |    |      |                                      |
|           | t |    |    |      |                                      |
|           | s |    |    |      |                                      |
|           | : |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| **T       |   |    |    |      |                                      |
| REATMENTS |   |    |    |      |                                      |
| AND       |   |    |    |      |                                      |
| PR        |   |    |    |      |                                      |
| OPHYLAXIS |   |    |    |      |                                      |
| GIVEN**   |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| Allergies |   |    |    |      |                                      |
| [ٱ]{d     |   |    |    |      |                                      |
| ir="rtl"} |   |    |    |      |                                      |
| yes       |   |    |    |      |                                      |
| [ٱ]{d     |   |    |    |      |                                      |
| ir="rtl"} |   |    |    |      |                                      |
| no        |   |    |    |      |                                      |
| s         |   |    |    |      |                                      |
| pecify\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| Current   |   |    |    |      |                                      |
| me        |   |    |    |      |                                      |
| dications |   |    |    |      |                                      |
| [ٱ]{dir=  |   |    |    |      |                                      |
| "rtl"}yes |   |    |    |      |                                      |
| [ٱ]{dir   |   |    |    |      |                                      |
| ="rtl"}no |   |    |    |      |                                      |
| List\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| **[T      |   | [  | [ٱ | [ٱ   | med                                  |
| reatments |   | ٱ] | ]{ | ]{di | ication/dosage\_\_\_\_\_\_\_\_\_\_\_ |
| Gi        |   | {d | di | r="r | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| ven]{.und |   | ir | r= | tl"} | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| erline}** |   | =" | "r | decl |                                      |
|           |   | rt | tl | ined | med                                  |
| Emergency |   | l" | "} |      | ication/dosage\_\_\_\_\_\_\_\_\_\_\_ |
| Cont      |   | }Y | No | [ٱ   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| raception |   | es |    | ]{di | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|           |   |    | [ٱ | r="r |                                      |
| Gonorrhea |   | [  | ]{ | tl"} | med                                  |
| pr        |   | ٱ] | di | decl | ication/dosage\_\_\_\_\_\_\_\_\_\_\_ |
| ophylaxis |   | {d | r= | ined | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|           |   | ir | "r |      | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Chlamydia |   | =" | tl | [ٱ   |                                      |
| pr        |   | rt | "} | ]{di | med                                  |
| ophylaxis |   | l" | No | r="r | ication/dosage\_\_\_\_\_\_\_\_\_\_\_ |
|           |   | }Y |    | tl"} | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Tr        |   | es | [ٱ | decl | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| ichomonas |   |    | ]{ | ined |                                      |
| pr        |   | [  | di |      | med                                  |
| ophylaxis |   | ٱ] | r= | [ٱ   | ication/dosage\_\_\_\_\_\_\_\_\_\_\_ |
|           |   | {d | "r | ]{di | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Hepatitis |   | ir | tl | r="r | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| B vaccine |   | =" | "} | tl"} |                                      |
|           |   | rt | No | decl | med                                  |
| dT        |   | l" |    | ined | ication/dosage\_\_\_\_\_\_\_\_\_\_\_ |
| imm       |   | }Y | [ٱ |      | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| unization |   | es | ]{ | [ٱ   | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|           |   |    | di | ]{di |                                      |
| other     |   | [  | r= | r="r | med                                  |
| me        |   | ٱ] | "r | tl"} | ication/dosage\_\_\_\_\_\_\_\_\_\_\_ |
| dications |   | {d | tl | decl | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|           |   | ir | "} | ined | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|           |   | =" | No |      |                                      |
|           |   | rt |    | [ٱ   |                                      |
|           |   | l" | [ٱ | ]{di |                                      |
|           |   | }Y | ]{ | r="r |                                      |
|           |   | es | di | tl"} |                                      |
|           |   |    | r= | decl |                                      |
|           |   | [  | "r | ined |                                      |
|           |   | ٱ] | tl |      |                                      |
|           |   | {d | "} | [ٱ   |                                      |
|           |   | ir | No | ]{di |                                      |
|           |   | =" |    | r="r |                                      |
|           |   | rt | [ٱ | tl"} |                                      |
|           |   | l" | ]{ | decl |                                      |
|           |   | }Y | di | ined |                                      |
|           |   | es | r= |      |                                      |
|           |   |    | "r |      |                                      |
|           |   | [  | tl |      |                                      |
|           |   | ٱ] | "} |      |                                      |
|           |   | {d | No |      |                                      |
|           |   | ir |    |      |                                      |
|           |   | =" | [ٱ |      |                                      |
|           |   | rt | ]{ |      |                                      |
|           |   | l" | di |      |                                      |
|           |   | }Y | r= |      |                                      |
|           |   | es | "r |      |                                      |
|           |   |    | tl |      |                                      |
|           |   | [  | "} |      |                                      |
|           |   | ٱ] | No |      |                                      |
|           |   | {d |    |      |                                      |
|           |   | ir |    |      |                                      |
|           |   | =" |    |      |                                      |
|           |   | rt |    |      |                                      |
|           |   | l" |    |      |                                      |
|           |   | }Y |    |      |                                      |
|           |   | es |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| **COU     |   |    |    |      |                                      |
| NSELING** |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| Community |   |    |    |      |                                      |
| Resources |   |    |    |      |                                      |
| are       |   |    |    |      |                                      |
| available |   |    |    |      |                                      |
| to assist |   |    |    |      |                                      |
| you with  |   |    |    |      |                                      |
| recovery. |   |    |    |      |                                      |
| Your      |   |    |    |      |                                      |
| crisis    |   |    |    |      |                                      |
| advocate  |   |    |    |      |                                      |
| can be    |   |    |    |      |                                      |
| reached   |   |    |    |      |                                      |
| at ( )-   |   |    |    |      |                                      |
| \_\_\_\_  |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| Some one  |   |    |    |      |                                      |
| is        |   |    |    |      |                                      |
| available |   |    |    |      |                                      |
| to talk   |   |    |    |      |                                      |
| to you 24 |   |    |    |      |                                      |
| hours a   |   |    |    |      |                                      |
| day.      |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| **MEDICAL |   |    |    |      |                                      |
| FOLLOW    |   |    |    |      |                                      |
| UP**      |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| You have  |   |    |    |      |                                      |
| i         |   |    |    |      |                                      |
| dentified |   |    |    |      |                                      |
| \_\_      |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| as your   |   |    |    |      |                                      |
| primary   |   |    |    |      |                                      |
| h         |   |    |    |      |                                      |
| ealthcare |   |    |    |      |                                      |
| provider. |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| You       |   |    |    |      |                                      |
| should    |   |    |    |      |                                      |
| schedule  |   |    |    |      |                                      |
| a follow  |   |    |    |      |                                      |
| up        |   |    |    |      |                                      |
| ap        |   |    |    |      |                                      |
| pointment |   |    |    |      |                                      |
| with      |   |    |    |      |                                      |
| \         |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_to |   |    |    |      |                                      |
| be seen   |   |    |    |      |                                      |
| in        |   |    |    |      |                                      |
| \_        |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| days      |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| **        |   |    |    |      |                                      |
| AFTERCARE |   |    |    |      |                                      |
| INSTR     |   |    |    |      |                                      |
| UCTIONS** |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| **Within  |   |    |    |      |                                      |
| 2 days of |   |    |    |      |                                      |
| this      |   |    |    |      |                                      |
| visit**   |   |    |    |      |                                      |
| (         |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_) |   |    |    |      |                                      |
| Talk with |   |    |    |      |                                      |
| your      |   |    |    |      |                                      |
| advocate  |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| **2 weeks |   |    |    |      |                                      |
| after     |   |    |    |      |                                      |
| this      |   |    |    |      |                                      |
| visit**   |   |    |    |      |                                      |
| (         |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_) |   |    |    |      |                                      |
| Obtain a  |   |    |    |      |                                      |
| repeat    |   |    |    |      |                                      |
| pregnancy |   |    |    |      |                                      |
| test if   |   |    |    |      |                                      |
| you did   |   |    |    |      |                                      |
| not take  |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| emergency |   |    |    |      |                                      |
| contr     |   |    |    |      |                                      |
| aception. |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| If you    |   |    |    |      |                                      |
| chose not |   |    |    |      |                                      |
| to take   |   |    |    |      |                                      |
| me        |   |    |    |      |                                      |
| dications |   |    |    |      |                                      |
| for       |   |    |    |      |                                      |
| p         |   |    |    |      |                                      |
| revention |   |    |    |      |                                      |
| of STD's  |   |    |    |      |                                      |
| you       |   |    |    |      |                                      |
| should go |   |    |    |      |                                      |
| for       |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| testing.  |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| **4 -8    |   |    |    |      |                                      |
| weeks     |   |    |    |      |                                      |
| after     |   |    |    |      |                                      |
| this      |   |    |    |      |                                      |
| visit**   |   |    |    |      |                                      |
| (         |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_) |   |    |    |      |                                      |
| If you    |   |    |    |      |                                      |
| plan to   |   |    |    |      |                                      |
| complete  |   |    |    |      |                                      |
| the       |   |    |    |      |                                      |
| Hepatitis |   |    |    |      |                                      |
| B         |   |    |    |      |                                      |
| va        |   |    |    |      |                                      |
| ccination |   |    |    |      |                                      |
| series    |   |    |    |      |                                      |
| follow up |   |    |    |      |                                      |
| with your |   |    |    |      |                                      |
| primary   |   |    |    |      |                                      |
| provider  |   |    |    |      |                                      |
| or local  |   |    |    |      |                                      |
| health    |   |    |    |      |                                      |
| de        |   |    |    |      |                                      |
| partment. |   |    |    |      |                                      |
| Vac       |   |    |    |      |                                      |
| cinations |   |    |    |      |                                      |
| should    |   |    |    |      |                                      |
| occur in  |   |    |    |      |                                      |
| 4- 8      |   |    |    |      |                                      |
| weeks and |   |    |    |      |                                      |
| 6 months  |   |    |    |      |                                      |
| If no     |   |    |    |      |                                      |
| period    |   |    |    |      |                                      |
| has       |   |    |    |      |                                      |
| occurred  |   |    |    |      |                                      |
| in this   |   |    |    |      |                                      |
| time you  |   |    |    |      |                                      |
| should    |   |    |    |      |                                      |
| have a    |   |    |    |      |                                      |
| repeat    |   |    |    |      |                                      |
| pregnancy |   |    |    |      |                                      |
| test.     |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| **6-8     |   |    |    |      |                                      |
| weeks     |   |    |    |      |                                      |
| after     |   |    |    |      |                                      |
| this      |   |    |    |      |                                      |
| visit**   |   |    |    |      |                                      |
| (         |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_) |   |    |    |      |                                      |
| If you    |   |    |    |      |                                      |
| plan to   |   |    |    |      |                                      |
| have an   |   |    |    |      |                                      |
| HIV       |   |    |    |      |                                      |
| antibody  |   |    |    |      |                                      |
| test,     |   |    |    |      |                                      |
| contact   |   |    |    |      |                                      |
| your care |   |    |    |      |                                      |
| provider  |   |    |    |      |                                      |
| or local  |   |    |    |      |                                      |
| health    |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| d         |   |    |    |      |                                      |
| epartment |   |    |    |      |                                      |
| to        |   |    |    |      |                                      |
| arrange   |   |    |    |      |                                      |
| testing.  |   |    |    |      |                                      |
| Testing   |   |    |    |      |                                      |
| should    |   |    |    |      |                                      |
| occur as  |   |    |    |      |                                      |
| soon as   |   |    |    |      |                                      |
| possible, |   |    |    |      |                                      |
| with      |   |    |    |      |                                      |
| repeat    |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| testing   |   |    |    |      |                                      |
| at 6      |   |    |    |      |                                      |
| weeks, 3  |   |    |    |      |                                      |
| months    |   |    |    |      |                                      |
| and 6     |   |    |    |      |                                      |
| months    |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| Safety    |   |    |    |      |                                      |
| planning  |   |    |    |      |                                      |
| offered   |   |    |    |      |                                      |
| \_\_yes   |   |    |    |      |                                      |
| \_\_no    |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| You are   |   |    |    |      |                                      |
| entitled  |   |    |    |      |                                      |
| to copies |   |    |    |      |                                      |
| of your   |   |    |    |      |                                      |
| records   |   |    |    |      |                                      |
| at your   |   |    |    |      |                                      |
| request   |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+
| **\_\_\_  |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_        |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_\_ |   |    |    |      |                                      |
| \_        |   |    |    |      |                                      |
| \_\_\_\_\ |   |    |    |      |                                      |
| _\_\_\_** |   |    |    |      |                                      |
|           |   |    |    |      |                                      |
| PRINTED   |   |    |    |      |                                      |
| NAME OF   |   |    |    |      |                                      |
| MEDICAL   |   |    |    |      |                                      |
| PROVIDER  |   |    |    |      |                                      |
| OR NURSE  |   |    |    |      |                                      |
| EXAMINER  |   |    |    |      |                                      |
| SIGNATURE |   |    |    |      |                                      |
| OF        |   |    |    |      |                                      |
| MEDICAL   |   |    |    |      |                                      |
| PROVIDER  |   |    |    |      |                                      |
| OR NURSE  |   |    |    |      |                                      |
| EXAMINER  |   |    |    |      |                                      |
| DATE      |   |    |    |      |                                      |
+-----------+---+----+----+------+--------------------------------------+

**CONSENT TO ADMINISTER**

**EMERGENCY CONTRACEPTION**

Patient ID

+-----------------------------------------------------------------------+
| **CRITERIA** : Less than 120 hours (5 days) since first assault,      |
|                                                                       |
| Of reproductive age                                                   |
|                                                                       |
| Negative pregnancy test                                               |
+-----------------------------------------------------------------------+
| **INFORMATION FOR YOU**: The hormone medication that is administered  |
| by this facility or practitioner is considered an emergency treatment |
| to [prevent]{.underline} pregnancy. This treatment is 98% effective   |
| to prevent pregnancy. Emergency Contraception is not the same as "The |
| Morning After Pill"( RU486) and will not induce abortion. Emergency   |
| Contraception will not harm a pregnancy that may already be present   |
| but undetectable.                                                     |
|                                                                       |
| There are no serious side effects from Emergency Contraception and    |
| almost all women can use it safely. Women with a history of clotting  |
| diseases, severe hypertension, smokers over age 40, prior stoke or    |
| heart attack should not use the estrogen containing forms. The most   |
| common side effects are nausea and vomiting. Other side effects       |
| include headaches, breast tenderness, fatigue, and dizziness.         |
+-----------------------------------------------------------------------+
| YOUR INFORMED CONSENT OR REFUSAL TO RECEIVE THIS MEDICATION:          |
+-----------------------------------------------------------------------+
| I have been screened for my personal risk and informed of the         |
| benefits and risks, side effects and limits of this drug. I           |
| understand that it has been shown effective in pregnancy prevention   |
| but is not 100% guaranteed. I have the opportunity to read this paper |
| and have had my questions answered concerning the administration of   |
| this drug.                                                            |
|                                                                       |
| I will not hold this facility, practitioner or nurse examiner         |
| responsible for any pregnancy that might be preexisting but           |
| undetectable, or for any pregnancy that might result from incorrect   |
| use of this medication or despite use of this medication.             |
|                                                                       |
| I hereby consent to treatment and I want to take the medication for   |
| the intention of preventing pregnancy that may result from the sexual |
| assault. I authorize                                                  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ to     |
| give me hormone for the purpose of emergency contraception. I         |
| understand that I can withdraw my consent at any time by choosing not |
| to take the medication.                                               |
|                                                                       |
| X\_\_\_\_\                                                            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                  |
| X\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_         |
|                                                                       |
| Signature of patient or guardian date witness                         |
+-----------------------------------------------------------------------+
| I understand that medical personnel have chosen not to recommend      |
| emergency contraception for me because...                             |
|                                                                       |
| [ٱ]{dir="rtl"}positive pregnancy test [ٱ]{dir="rtl"}prior             |
| hysterectomy [ٱ]{dir="rtl"} other                                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                        |
|                                                                       |
| X\_\_\_\_\                                                            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                  |
| X\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_         |
|                                                                       |
| Signature of patient or guardian date witness                         |
+-----------------------------------------------------------------------+
| **Consent of Decline for Emergency Contraception**                    |
+-----------------------------------------------------------------------+
| The purpose and intent of emergency contraception has been explained  |
| to me Emergency Contraception has been offered to me, I choose not to |
| receive this medication and understand that my refusal could result   |
| in pregnancy related to sexual assault.                               |
|                                                                       |
| X\_\_\_\_\                                                            |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                                  |
| X\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_         |
|                                                                       |
| Signature of patient or guardian date witness                         |
+-----------------------------------------------------------------------+

**Evidence**

**Chain of Custody**

Patient ID

  ----------------- ----------------- ----------------- -----------------
  **\#**            **OSP Rape Kit**  **\#**            **OSP Suspect
                                                        Kit**

                    Oral swab                           Oral swab
                    standard                            standard

                    Oral swab                           Head hair combing
                    (sodomy)                            

                    Head hair combing                   Head hair
                                                        standard

                    Head hair                           Pubic hair
                    standard                            combing

                    Pubic hair                          Pubic hair
                    combing                             standard

                    Pubic hair                          Penis shaft swab
                    standard                            

                    Vaginal swabs                       Scrotum swabbing

                    Vaginal slide                       

                    Cervical swab                       

                    Cervical slide                      

                    Anal swabs                          

                    Anal slide                          

                    Control swab                        

                    OTHER ITEMS                         

                                                        

                                                        

                                                        

                                                        

                                                        
  ----------------- ----------------- ----------------- -----------------

The above items were collected
by:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name and title

on
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_at
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Month/Day/ Year military time

Chain of custody after the collection of evidence is as follows:

I\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ released the above evidence to
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature of examiner Signature of L.E. officer

of \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ at
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ on
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

agency military time month/day/year

+-----------------------------------------------------------------------+
| **CONSENT FOR MEDICAL-LEGAL EXAM**                                    |
+-----------------------------------------------------------------------+
| In addition to consent for the medical evaluation and treatment given |
| to this facility, I give consent for the collection of evidence for   |
| sexual assault, which may or may not include photographs. The         |
| evidence collected and documentation forms will be released to law    |
| enforcement for the sole purpose of investigation and prosecution. I  |
| understand I may withdraw consent at any time for any portion of the  |
| exam.                                                                 |
|                                                                       |
| The original document will be kept with my medical record.            |
|                                                                       |
| I consent and authorize\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ of    |
| Warm Springs Health andWellnessCenter, to perform                     |
|                                                                       |
| Medical Provider                                                      |
|                                                                       |
| A medical-legal exam for the purpose of investigation and treatment.  |
|                                                                       |
| X\                                                                    |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\                                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Signature of patient/guardian Name and relationship of guardian       |
|                                                                       |
| X\                                                                    |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\                                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Signature of medical provider Printed name of provider                |
+-----------------------------------------------------------------------+
| RRR                                                                   |
|                                                                       |
| **RELEASE OF INFORMATION**                                            |
+-----------------------------------------------------------------------+
| I consent to release information and evidence collected from this     |
| exam on \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
|                                                                       |
| Month/day/year                                                        |
|                                                                       |
| to law enforcement and prosecution                                    |
|                                                                       |
| **From** Warm Springs Health and Wellness Center 1270 Kot-Num Rd.     |
| Warm Springs OR, 97761                                                |
|                                                                       |
| **To:**                                                               |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |
|                                                                       |
| agency agency agency                                                  |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |
|                                                                       |
| street address street address street address                          |
|                                                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_            |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_              |
|                                                                       |
| city/state/ zip code city/state/ zip code city/state/ zip code        |
|                                                                       |
| X\                                                                    |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\                                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Signature of patient/guardian Name and relationship of guardian       |
|                                                                       |
| X\                                                                    |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| \_\                                                                   |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                                                                       |
| Signature of medical provider Printed name of provider                |
+-----------------------------------------------------------------------+