|
STI Consent form
|
|
|
SANE Nurse(s)
• • •
|
|
|
Language
|
Interpreter Name
|
|
Patient Accompanied By
|
Referral Source
• • •
|
|
Date of Assault
|
|
|
Follow-Up Contact Requested
|
Police Report
|
|
Ok to Call
|
Officer/Det Name & Agency
|
|
Sexual Assault Medical History
|
|
|
LMP
|
|
|
Anal Injuries/Sympt Prior to SA
|
Genital Symptoms Prior to SA
• • •
|
|
Other Pertinent Injuries/Symptom
|
Oral Injuries Prior to Assault
|
|
Any Alcohol within 48 hours?
|
If yes, amount/time of ingestion
|
|
SA Related to Domestic Violence?
|
|
|
|
|
|
Offender Information
|
|
|
|
|
|
Offender Relationship
• • •
|
Offender Age(s)
|
|
Number of Offenders
|
Offender Gender
• • •
|
|
Describe Family Relationship
|
|
|
Condom Used
|
If yes, describe
|
|
Use of Weapon
|
If yes, describe
|
|
Use of Force
|
If yes, describe
|
|
Use of Threat
|
If yes, describe
|
|
Position of Authority
|
If yes, describe
|
|
Did Offender strangle Patient
|
See Strangulation Form
|
|
Patient Affect/Demeanor
|
|
|
Eye Contact
• • •
|
Other
|
|
Speech
• • •
|
Other
|
|
Responsive to Clinician
• • •
|
Other
|
|
Non-Verbal Expressions/Behaviors
• • •
|
Other
|
|
Appearance
• • •
|
Other
|
|
Comments on abnormal appearance
|
Other Comments on Demeanor
|
|
SANE Physical Exam
|
|
|
Past Medical History
|
Past Surgical History
|
|
General Assessment~Normal
• • •
|
Comments
|
|
ABCs
|
Comments
|
|
Oral
|
Comments
|
|
Pulmonary
|
Comments
|
|
Muscular/Skel
|
Comments
|
|
Skin
|
Comments
|
|
Cardiovascular
|
Comments
|
|
Abdomen
|
Comments
|
|
Neuro
|
Comments
|
|
Other
|
|
|
Urine Dip
|
|
|
Glucose
|
Bilirubin
|
|
Ketones
|
Specific Gravity
|
|
Blood
|
pH
|
|
Protein
|
Urobilinogen
|
|
Nitrites
|
Leukocytes
|
|
SANE Patient Narrative
|
|
|
SANE Patient Medical History/Narrative
|
|
|
SANE Summary of Acts
|
|
|
Penetration of Female Genitalia
• • •
|
Comments
|
|
Penetration of Anus
• • •
|
Comments
|
|
Oral Copulation of Genitals
• • •
|
Location:
|
|
Oral Copulation of Anus
• • •
|
Location
|
|
Masturbation
• • •
|
Location
|
|
Did Ejaculation Occur?
• • •
|
Location
|
|
Fondling of Patient
|
Location
|
|
Offender Licked Patient
|
Location
|
|
Offender Kissed Patient
|
Location
|
|
Offender Bit Patient
|
Location
|
|
Offender Sucked Patient
|
Location
|
|
Patient Bit Offender
|
Location of Injury
|
|
Did Patient Injure Offender
|
If yes, describe:
|
|
Additional Comments
|
|
|
|
|
|
Additional Medical Treatment
|
|
|
Additional Medical Consultation
|
|
|
Physician
|
|
|
Additional Reporting
|
|
|
Adult Protective Services Needed
|
|
|
Caseworker Name & Phone Number
|
Other, Agency/Contact Info
|
|
Comments
|
Location
|
|
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
/
|
|
Doxycycline
|
Lot # & Exp. Date
/
|
|
Diphenhydramine-Benadryl
• • •
|
|
|
Lidocaine hydrochloride 1% Injectable
|
Lot # & Exp. Date
/
|
|
0.9% sodium chloride injection
|
Lot # & Exp. Date
/
|
|
Ibuprofen
• • •
|
Lot # & Exp. Date
/
|
|
Comments for medications not given:
|
|
|
SANE Progress Notes
|
|
|
SANE Progress Notes
|
|
