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close this bookClinical 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.)
View the document(introduction...)
View the documentPreface
View the documentAcknowledgements
View the documentAbbreviations and acronyms used in this guide
View the documentIntroduction
View the documentSTEP 1 - Making preparations to offer medical care to rape survivors
View the documentSTEP 2 - Preparing the survivor for the examination
View the documentSTEP 3 - Taking the history
View the documentSTEP 4 - Collecting forensic evidence
View the documentSTEP 5 - Performing the physical and genital examination
View the documentSTEP 6 - Prescribing treatments
View the documentSTEP 7 - Counselling the survivor
View the documentSTEP 8 - Follow-up care of the survivor
View the documentAnnex 1 · Information needed to develop a local protocol
View the documentAnnex 2 · Sample consent form
View the documentAnnex 3 · Sample history and examination form
View the documentAnnex 4 · Pictograms
View the documentAnnex 5 · Protocols for treatment of STIs
View the documentAnnex 6 · Protocols for post-exposure prophylaxis of HIV infection
View the documentAnnex 7 · Protocols for emergency contraception
View the documentAnnex 8 · Minimum care for rape survivors in low-resource settings
View the documentAnnex 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

No


Yes

No

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

No

Evidence of pregnancy

Yes

No

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: ______________