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SANE CHILD INTAKE
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Child Consent Form
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SANE Nurse
• • •
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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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Child lives with
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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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CYFD/LE Report Time
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CYFD/LE Contact
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Responding Officer/Agency
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Responding Detective/Agency
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Officer present at time of Exam
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Law Enforcement Case #
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Is child safe in current home?
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If no, explain
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Is guardian supportive/protective
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If no, explain
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Date of Last Known Contact
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Time of Last Known Contact
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Date of Last Known Assault
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Time of Last Known 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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Human Trafficking Assessment
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PHYSICAL ASSESSMENT
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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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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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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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Urine HCG
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Serum HCG
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Other Lab Studies:
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SEXUAL ABUSE MEDICAL HISTORY
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Sexual Abuse Related 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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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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Genital Wash/Wipe
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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
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Chewed Gum
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Additional Comments
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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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Offender(s)
• • •
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Describe Family Relationship
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Number of Offenders
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Offender Age(s)
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Offender(s) Gender
• • •
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Offender(s) Have Access to Child?
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Use of Weapon
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If yes, describe:
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Use of Force
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If yes, describe
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Use of Verbal Threat
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If yes, describe
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Use of Physical Threat
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If yes, describe
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Use of Position of Authority
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If yes, describe
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Offender Hurt Child in Any Way?
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If yes, describe
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SANE Patient Medical History
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Historian Medical History for Pt.
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Patient Medical History
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SANE Summary of Acts
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Penetration of Female Genitalia
• • •
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Comments
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Penetration of Anus
• • •
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Comments
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Oral Copulation of Genitals
• • •
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Comments
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Oral Copulation of Anus
• • •
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Comments
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Masturbation
• • •
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Comments
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Did Ejaculation Occur
• • •
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Specify Location:
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Comments
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Did Offender Fondle Patient
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Location
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Did Offender Lick Patient
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Location
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Did Offender Kiss Patient
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Location
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Did Offender Bite Patient
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Location
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Did Offender Suck On Patient
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Location
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Did Offender Strangle/Choke Patient
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Strangulation Assessment
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Did Patient Injure Offender
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If yes, describe:
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Did Patient Bite Offender
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Location
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Did Patient Ingest Drugs/Alcohol
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Comments
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Did Offender Use Lubricant
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Comments
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Did Offender Use Videos/Photos
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Comments
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Additional Comments
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Patient Clothing Information
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Clothing Collected
• • •
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Clothing Description
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Clothing Information
• • •
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Photos of Clothing
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Approximate Number of Photos
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Type of Film
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PEDIATRIC SEXUAL ABUSE EXAM
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Genital/Anal Examination
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Patient Position
• • •
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Exam Techniques
• • •
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Tanner Stage
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Adjunct Therapies and Methods
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Magnification Used
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Alternative Light Source
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If (+) ALS, describe:
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Type of ALS:
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Toluidine Blue Dye Used:
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Environmental Debris
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If yes, describe:
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Fingernail Evidence
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If yes, describe:
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Miscellaneous Evidence
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If yes, describe
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Cultures
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STI Cultures - Vaginal
• • •
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STI Cultures - Rectal
• • •
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STI Cultures - Oral
• • •
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Other Lab Studies:
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Additional Medical Treatment
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Additional Medical Consultation
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Rationale
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Physician
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Time
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Additional Reporting
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Child Protective Services Needed
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Caseworker Name
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Caseworker Phone Number
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Other, Agency/Contact Info
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Pediatric Pharmacy Log
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Acetaminophen (Enter cc/ml dosage)
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Ibuprofen (Enter cc/ml dosage)
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Comments
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Infant Pharmacy Log
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Acetaminophen (Enter cc/ml dosage)
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Ibuprofen (Enter cc/ml dosage)
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Comments
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Progress Notes
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Progress Notes
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Female Child Vagina
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Female Child Vagina: Additional Comments
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Female Child Anus
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Female Child Anus: Additional Comments
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Female Child Body (Front & Back)
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Female Child Body (Front & Back): Comments
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Female Child Body (Lateral)
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Female Child Body (Lateral): Comments
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Female Child Head
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Female Child Head: Additional Comments
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Hands
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Hands: Additional Comments
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Feet
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Feet: Additional Comments
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Mouth
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Mouth: Additional Comments
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Gender Neutral Face & Neck Lateral
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Gender Neutral Face & Neck Lateral: (Comments)
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Gender Neutral Anterior Neck
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Gender Neutral Anterior Neck: (Comments)
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Gender Neutral Facial/Head Front & Back
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Gender Neutral Facial/Head Font & Back: (Comments)
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Eye Diagram Side-to-Side
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Eyes: (Comments)
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Eye Diagram Forward-Downward-Upward
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Eyes: (Comments)
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Toddler Body Map
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Toddler Body Map: Additional Comments
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Toddler Lateral Body Map
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Toddler Lateral Body Map: Comments
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Baby Body Map
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Baby Body Map: Comments
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