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Adult Consent Form
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Patient age at time of exam
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SANE Nurse(s)
• • •
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SANE Dispatch Time
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SANE Arrival Time
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Patient Arrival Time
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Patient Discharge Time
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Case Start Time
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Comments pertaining to time
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Ok to Call
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Follow-Up Contact Requested
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Patient Accompanied By
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Present During SANE Medical History
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Present During SANE Exam
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Referral Source
• • •
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Other Referral Source
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Language
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Interpreter Name
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Interpreter Agency
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Police Report
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Law Enforcement Agent & Case #
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Officer present at time of Exam
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Date of Assault
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Time of Assault
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Location of Assault
• • •
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Other Location of Assault
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Address of Assault, If Known
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SANE Physical Assessment
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LMP
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Current Immunization Status
• • •
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Past Medical History
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Past Surgical History
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Pain Scale
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General Assessment~Normal
• • •
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General Assessment~Abnormal
• • •
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Additional General Comments
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Head Assessment~ Normal
• • •
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Head Assessment~Abnormal
• • •
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Additional Head Comments
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Eye Assessment~Normal
• • •
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Eye Assessment~Abnormal
• • •
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Additional Eye Comments
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Ears Assessment~Normal
• • •
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Ears Assessment~Abnormal
• • •
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Additional Ears Comments
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Nose Assessment~Normal
• • •
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Nose Assessment~Abnormal
• • •
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Additional Nose Comments
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Oropharynx Assessment~Normal
• • •
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Oropharynx Assessment~Abnormal
• • •
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Additional Oropharynx Comments
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Neck Assessment~Normal
• • •
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Neck Assessment~Abnormal
• • •
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Additional Neck Comments
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Cardiovascular Assessment~Normal
• • •
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Cardiovascular Assessment~Abnormal
• • •
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Additional Cardiovascular Comments
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Pulmonary Assessment~Normal
• • •
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Pulmonary Assessment~Abnormal
• • •
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Additional Pulmonary Comments
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Abdomen Assessment~Normal
• • •
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Abdomen Assessment~Abnormal
• • •
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Additional Abdomen Comments
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Skin Assessment~Normal
• • •
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Skin Assessment~Abnormal
• • •
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Additional Skin Comments
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Musculoskeletal Assessment~Normal
• • •
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Musculoskeletal Assessment~Abnormal
• • •
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Additional Musculoskeletal Comments
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Breast/Chest Assessment~Normal
• • •
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Breast/Chest Assessment~Abnormal
• • •
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Additional Chest/Breast Comments
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Upper Extremities Assessment~Normal
• • •
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Upper Extremities Assessment~Abnormal
• • •
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Additional Upper Extrem Comments
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Lower Extremities Assessment~Normal
• • •
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Lower Extrem Assessment~Abnormal
• • •
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Additional Lower Extrem Comments
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Neuro Assessment~Normal
• • •
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Neuro Assessment~Abnormal
• • •
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Additional Neuro Comments
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Psychiatric Assessment~Normal
• • •
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Psychiatric Assessment~Abnormal
• • •
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Additional Psychiatric Comments
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Suicide Assessment
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Non-Fatal Strangulation Assessment
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Strangulation Assessment
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Offender Slapped Pt. Open Hand
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Location
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Offender Hit Pt. with Fist(s)
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Location
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Offender Hit Pt. with Object(s)
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Location
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Offender Bit Patient
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Location
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Patient Bit Offender
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Location
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Did Patient Injure Offender
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If yes, describe:
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Manner of Strangulation
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Neck pressure felt during strangulation incident(s) on a 0-10 scale
• • •
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Additional Comments
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How Long did the strangulation(s) last? (Seconds/minutes/cannot recall
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Additional Comments
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How many times did the strangulation(s) occur ?
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What made the assailant stop strangling the patient ?
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Patient position and location following the strangulation incident(s)?
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Patient position and location prior to strangulation incident?
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Methods of Strangulation
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Assailant was:
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Methods of Strangulation
• • •
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Pt. Comments Related to the Methods of Strangulation
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If Ligature: Name/description
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Type of Strangulation(s) Occurred ?
• • •
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Was the Patient Smothered ?
• • •
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If "Yes": Describe
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Was the patient shaken during the incident ?
• • •
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If Shaken: Describe
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Did the assailant apply pressure to your chest or upper abdomen ?
• • •
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If pressure was applied: Describe
|
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Was the patients head or face pound against any object during the incident ?
• • •
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Additional Comments
|
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Was the assailant wearing any jewelry on hands or wrists ?
• • •
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If "Yes": Describe
|
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Have you been strangled prior to this event ?
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What did the assailant say before, during, or after the strangulation(s) ?
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What did the patient think was going to happen during the strangulation?
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Additional Comments
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Strangulation Physical Assessment #1
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Strangulation Physical Assessment pg 2
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Strangulation Physical Assessment pg 3
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Strangulation Physical Assessment pg 4
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Emergency Services Referred/Required
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Urine Dip
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Glucose
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Bilirubin
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Ketones
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Specific Gravity
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Blood
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pH
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Protein
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Urobilinogen
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Nitrites
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Leukocytes
|
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Urine Collected for DFSA
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Signs & Symptoms of DFSA
• • •
|
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Comments Related to DFSA:
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Serum HCG
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Urine HCG
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Other Lab Studies:
|
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SEXUAL ASSAULT MEDICAL HISTORY
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Genital Symptoms Prior to SA
• • •
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Other Genital Injuries/Symptoms
|
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Anal Injuries/Sympt Prior to SA
• • •
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Other Anal Injuries/Symptoms
|
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Oral Injuries/Sympt Prior to SA
• • •
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Other Oral Injuries/Symptoms
|
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Other Pertinent Injuries/Symptom
|
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Consensual Sex within 5 days?
|
Of what nature?
• • •
|
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Any Alcohol within 48 hours?
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If yes, amount of ingestion
|
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If yes, time of Ingestion
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SA Related to Domestic Violence
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Victim Post-Assault Hygiene
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Urinated
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Defecated
|
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Bathed
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Showered
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Douched
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Genital Wash/Wipe
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Removed/Inserted Diaphragm
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Removed/Inserted Tampon
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Removed/Inserted Condom
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Removed/Inserted Other
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Brushed Teeth
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Gargled/Mouthwash
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Fluid Intake
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Food Consumption
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Vomited
|
Smoked
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Chewed Gum
|
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Patient Affect/Demeanor
|
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Eye Contact
• • •
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Other
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Speech
• • •
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Other
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Responsive to Clinician
• • •
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Other
|
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Non-Verbal Expressions/Behaviors
• • •
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Other
|
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Appearance
• • •
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Other
|
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Comments on abnormal appearance
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Other Comments on Demeanor
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Offender Information
|
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Name of suspected offender(s)
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Number of Offenders
|
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Offender Relationship to the Victim
• • •
|
Describe family relationship to the suspected offender
|
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Offender Age(s)
|
Offender Gender
• • •
|
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Use of Weapon
|
If yes, describe
|
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Use of Force
|
If yes, describe
|
|
Use of Verbal Threat
|
If yes, describe
|
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Use of Physical Threat
|
If yes, describe
|
|
Position of Authority
|
If yes, describe
|
|
Sexual Assault Patient Medical History of Events
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SANE Patient Medical History of Events
|
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SANE Summary of Acts
|
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Penetration of Female Genitalia
• • •
|
Comments
|
|
Penetration of Anus
• • •
|
Comments
|
|
Oral Copulation of Genitals
• • •
|
Comments
|
|
Oral Copulation of Anus
• • •
|
Comments
|
|
Masturbation
• • •
|
Comments
|
|
Did Ejaculation Occur?
• • •
|
Comments
|
|
Condom Used
|
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Did Offender Fondle Patient
|
Location
|
|
Did Offender Lick Patient
|
Location
|
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Did Offender Kiss Patient
|
Location
|
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Did Offender Bite Patient
|
Location
|
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Did Offender Suck On Patient
|
Location
|
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Did Patient Injure Offender
|
If yes, describe:
|
|
Did Patient Bite Offender
|
Location
|
|
Did Offender Use Lubricant
|
Comments
|
|
Did Offender Use Videos/Photos
|
Comments
|
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Additional Comments
|
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Did Offender Strangle/Choke Patient
|
Strangulation Assessment
|
|
Patient Clothing Information
|
|
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Clothing Collected
• • •
|
Clothing Description
|
|
SANE Clothing Information
• • •
|
|
|
Photos of Clothing
|
Number of Photos
|
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Type of Film
|
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Genital/Anal Examination
|
|
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Patient Consented to Genital/Anal Exam
|
Patient Consented to Genital/Anal Pictures
|
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Patient Position
• • •
|
Other Position
|
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Exam Techniques
• • •
|
|
|
Adjunct Therapies and Methods:
|
|
|
Speculum Used
|
Rationale, No Speculum Utilization
• • •
|
|
Magnification Used
|
|
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Alternative Light Source
|
If (+) ALS, describe:
|
|
Type of ALS:
|
|
|
Toluidine Blue Dye Used:
|
If yes, describe:
|
|
Environmental Debris
|
If yes, describe:
|
|
Fingernail Evidence
|
If yes, describe
|
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Miscellaneous Evidence
|
If yes, describe
|
|
Additional Medical Treatment:
|
|
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Additional Medical Consultation
|
Physician
|
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Time
|
Rationale
|
|
Additional Reporting:
|
|
|
Adult Protective Services Needed
|
Caseworker Name
|
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Caseworker Phone Number
|
Other Agency/Contact Info
|
|
Child Protective Services Needed
|
Caseworker Name
|
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Caseworker Phone Number
|
Other, Agency/Contact Info
|
|
Adult Pharmacy Log
|
|
|
Acetaminophen
• • •
|
Lot # & Exp. Date
/
|
|
Promethazine/Phenergan
• • •
|
Lot # & Exp. Date
/
|
|
Metronidazole/Flagyl
|
Lot # & Exp. Date
/
|
|
T-Relief Topical Pain Relieving Ointment
|
Lot # & Exp. Date
/
|
|
Ondansetron-Zofran
|
Lot # & Exp. Date
/
|
|
Azithromycin
|
Lot # & Exp. Date
/
|
|
Levonorgestrel-Plan B
|
Lot # & Exp. Date
/
|
|
Bacitracin/neomycin/polymyxinB topical Ointment
|
Lot # & Exp. Date
/
|
|
Ceftriaxone
|
Lot # & Exp. Date
/
|
|
Lidocaine hydrochloride 1% Injectable
|
Lot # & Exp. Date
/
|
|
Doxycycline
|
|
|
Diphenhydramine-Benadryl
• • •
|
Lot # & Exp. Date
/
|
|
0.9% sodium chloride injection
|
Lot # & Exp. Date
/
|
|
Ibuprofen
• • •
|
Lot # & Exp. Date
/
|
|
Comments for related medications:
|
|
|
Progress Notes
|
|
|
Progress Notes
|
|
|
Female Diagrams
|
|
|
Gender Neutral Facial/Head Front & Back
|
Gender Neutral Facial/Head Font & Back: (Comments)
|
|
Gender Neutral Face & Neck Lateral
|
Gender Neutral Face & Neck Lateral: (Comments)
|
|
Gender Neutral Anterior Neck
|
Gender Neutral Anterior Neck: (Comments)
|
|
Eye Diagram Side-to-Side
|
Eyes: (Comments)
|
|
Eye Diagram Forward-Downward-Upward
|
Eyes: (Comments)
|
|
Female Face (Front & Lateral)
|
Female Face (Front & Lateral): Comments
|
|
Female Body (Lateral)
|
Female Body (Lateral): Comments
|
|
Female Body (Front & Back)
|
Female Body (Front & Back): Comments
|
|
Vagina and Anus
|
Vagina and Anus: Additional Comments
|
|
Specview of Cervix
|
Specview of Cervix: Additional Comments
|
|
Breasts
|
Breasts: Additional Comments
|
|
Mouth
|
Mouth: Additional Comments
|
|
Hands
|
Hands: Additional Comments
|
|
Feet
|
Feet: Additional Comments
|
