Medical history:

STATE OF ALASKA
Victim Sexual Assault Evidence Kit Medical History – Step 1B
TO BE COMPLETED BY THE MEDICAL PROVIDER
Time assessment started: _________________ pm Time assessment ended: ________________ MEDICAL HISTORY:
If yes, list: ___________________________________________________________ If yes, list: _________________________________________________________________________ Vaccine History:
Current medications (prescriptions, contraceptives, over-the-counter, herbal or home remedies):
If yes, list __________________________________________________________________________ Is the victim currently being treated for any chronic medical or mental health conditions that may impact the exam? If yes, describe ____________________________________________________________________________________ _______________________________________________________________________________________________________________ Is the victim at risk of having withdrawal/DT’s during the exam? If yes, is there a seizure history associated with withdrawal? Does the victim have any observed disabilities? If yes, describe ____________________________________________________________________________________ _______________________________________________________________________________________________________________ Does the victim have a safe living environment to return to? Any recent medical procedures/treatments (30 days) that may affect the interpretation of any physical or forensic findings? If yes, describe __________________________________________________________________________________________________ Did the victim seek medical care prior to this examination that may affect the interpretation of any physical findings or potential forensic evidence? If yes, describe __________________________________________________________________________________________________ Where: _____________________________________________ Reason for care: _________________________________________ Page 1 of 4
Rev. Date – Aug/23/2013
STATE OF ALASKA
Victim Sexual Assault Evidence Kit Medical History – Step 1B
GYNECOLOGICAL HISTORY:
LMP: _____________________________ Was LMP normal (per victim):
If no, describe ___________________________________________________________________________________________________ G __________ P ___________ Delivery in the last 8 weeks: Does victim think she could be pregnant? If yes, how many weeks: _________________________________________ Has victim been treated for an STI in the last 6 weeks? Date: ___________________ For: _____________________________ Treated with: ________________________________ PHYSICAL ASSESSMENT:
Other: _______________________________________________ Vital Signs:
General:
Yes If yes, current pain level per victim is: ______ out of 10 (0 = none, 10 = worst possible) Location of pain: _________________________________________________________________________________________ Type of pain: ____________________________________________________________________________________________ What makes pain worse: ___________________________________________________________________________________ What makes pain better: ___________________________________________________________________________________ Additional information: ____________________________________________________________________________________ ANOGENITAL EXAM SUMMARY:
Was any discharge noted prior to or during manipulation of tissue (prior to insertion of speculum)? If yes, describe _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Was TBD used? If no, explain: __________________________________________ If no, explain: __________________________________________ Other: _____________________________________________________ if no, explain: ________________________________________________________________ if no, explain: __________________________________________________ Did the victim complain of pain or experience pain during the exam? If yes, describe _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Page 2 of 4
Rev. Date – Aug/23/2013
STATE OF ALASKA
Victim Sexual Assault Evidence Kit Medical History – Step 1B
ANATOMICAL SITE:
DESCRIBE:


LABORATORY TESTING/SPECIMENS COLLECTED:


RESULTS OBTAINED AT TIME OF EXAM:
Page 3 of 4
Rev. Date – Aug/23/2013
STATE OF ALASKA
Victim Sexual Assault Evidence Kit Medical History – Step 1B
Page 4 of 4
Rev. Date – Aug/23/2013

Source: http://dps.state.ak.us/CrimeLab/docs/SAforms/V3%20Medical%20history%20step%201B.pdf