Clinical Management of Survivors of Rape - A Guide to the Development of Protocols for Use in Refugee and Internally Displaced Person Situations (United Nations High Commissioner for Refugees (UNHCR) / Alto Comisionado de Naciones Unidas para los Refugiados (ACNUR) - WHO - OMS, 2001, 46 p.): Annex 3

Clinical Management of Survivors of Rape - A Guide to the Development of Protocols for Use in Refugee and Internally Displaced Person Situations (United Nations High Commissioner for Refugees (UNHCR) / Alto Comisionado de Naciones Unidas para los Refugiados (ACNUR) - WHO - OMS, 2001, 46 p.)

		(introduction...)
		Preface
		Acknowledgements
		Abbreviations and acronyms used in this guide
		Introduction
		STEP 1 - Making preparations to offer medical care to rape survivors
		STEP 2 - Preparing the survivor for the examination
		STEP 3 - Taking the history
		STEP 4 - Collecting forensic evidence
		STEP 5 - Performing the physical and genital examination
		STEP 6 - Prescribing treatments
		STEP 7 - Counselling the survivor
		STEP 8 - Follow-up care of the survivor
		Annex 1 · Information needed to develop a local protocol
		Annex 2 · Sample consent form
		Annex 3 · Sample history and examination form
		Annex 4 · Pictograms
		Annex 5 · Protocols for treatment of STIs
		Annex 6 · Protocols for post-exposure prophylaxis of HIV infection
		Annex 7 · Protocols for emergency contraception
		Annex 8 · Minimum care for rape survivors in low-resource settings
		Annex 9 · Additional resource materials

Annex 3 · Sample history and examination form

Sample form, page 1 of 4

CONFIDENTIAL

CODE:

Medical History and Examination Form - Post-Sexual Violence

1. GENERAL INFORMATION

First Name		Last Name
Address
Sex	Date of birth		Age
Date / time of exam	/	In the presence of

In case of a child include: Name of school, name of parents and/or guardian

2. THE INCIDENT

Date of incident:			Time of incident:
Description of incident (survivor's description)
Physical violence	Yes	No	Describe type and location
Type (beating, biting, pulling hair, etc.)
Use of restraints
Use of weapon(s)
Drugs/alcohol involved
Penetration	Yes	No	Not sure	Describe (oral, vaginal, anal, type of object)
Penis
Finger
Other (describe)
	Yes	No	Not sure	Location (oral, vaginal, anal, other location).
Ejaculation
Condom used

If use of restraints, drugs/alcohol involved and if the survivor is a child, also ask: Has this happened before, for how long, who is the perpetrator, is (s)he still a threat, etc. Also ask about bleeding from the vagina or the rectum, pain on walking, dysuria, pain on passing stool, signs of discharge, etc.

Sample form, page 2 of 4

3. MEDICAL HISTORY

After the incident, did the survivor

Yes

Vomit

Rinse mouth

Urinate

Change clothing

Defecate

Wash/bathe

Brush teeth

Use tampon/pad

Contraception use

Pill

IUD

Injection

Other
(specify)

Menstrual history

Last menstrual period

Menstruation at time of event

Yes

Evidence of pregnancy

Yes

Number of weeks pregnant

____ weeks

History of consenting intercourse (only if samples have been taken for DNA analysis)

Last consenting intercourse within a week prior to the assault

Date:

Name of individual:

Existing health problems

History of female genital cutting, type

Allergies

Current medication

Vaccination status

Vaccinated

Not vaccinated

Unknown

Comments

Tetanus

Hepatitis B

HIV/AIDS status

Know

Negative

Unknown

4. Medical examination

Appearance (clothing, hair, etc., obvious physical or mental disability?)
Mental state (calm, crying, anxious, cooperative, etc.)
Weight:	Height:	Pubertal stage (pre-pubertal, pubertal, mature):
Pulse rate	Blood pressure	Respiratory rate	Temperature
Physical findings Describe systematically, and draw on the attached body pictograms, the exact location of all wounds, bruises, petechiae, marks, etc. Document type, size, colour, form and other particulars. Be descriptive, do not interpret the findings.
Head and face			Mouth and nose
Eyes and ears			Neck
Chest			Back
Abdomen			Buttocks
Upper extremities			Lower extremities

5. GENITAL AND ANAL EXAMINATION

Vulva/scrotum	Introitus and hymen	Anus
Vagina/penis	Cervix	Bimanual/rectovaginal examination
Position of patient (supine, prone, knee-chest, lateral, mother's lap)
For genital examination:	For anal examination:

6. INVESTIGATIONS DONE

Type and location	Examined/sent to lab	Result

7. EVIDENCE TAKEN

Type and location	Sent to.../stored	Collected by/date

8. TREATMENTS PRESCRIBED

Treatment	Yes	No	Type and Comments
STI prevention
Emergency contraception
Wound treatment
Tetanus prophylaxis
Hepatitis B vaccination
Other

9. COUNSELLING, REFERRALS, FOLLOW-UP

General psychological status
Survivor plans to report to police OR has already made report				Yes	No
Survivor has a safe place to go	Yes	No	Has someone to accompany her/him			Yes	No
Counselling provided:
Referrals
Follow-up required
Date of next visit

Name of health worker conducting examination/interview:__________________
Title: __________________ Signature: ______________ Date: ______________