3 minutes to complete
A medical professional who has examined a patient who has alleged sexual assault is eligible to fill out the Forensic Medical Documentation Form.
Patient's Name:
Patient's Age:
Patient's Gender:
Patient's Date of Birth:
Patient's Address:
Patient's Phone Number:
Patient's Email Address:
Date of Exam:
Time of Exam:
Location of Exam:
Referring Physician:
Reason for Exam:
Patient's History:
Sexual Assault History:
Physical Exam Findings:
Medical Professional's Findings and Conclusions:
Recommended Course of Treatment:
Patient's Signature:
Medical Professional's Signature:
Date: