NON-FATAL STRANGULATION DOCUMENTATION FORM
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- June Fleming
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1 NON-FATAL STRANGULATION DOCUMENTATION FORM Patient Name: Date: Medical Record Number: _ Time: is a serious event that often occurs in the context of intimate partner violence (IPV). Many times strangulation presents NO VISIBLE INJURIES. It is important to ask about strangulation in all IPV cases, and document positive disclosure or any signs and symptoms. Event History How long did the strangulation last? seconds minutes cannot recall How many times did strangulation occur? Why/how did the strangulation stop? What type of strangulation occurred? (Check all that apply) Hanging Ligature Manual Other What was used to strangle the patient? Right hand Left hand Both hands Unknown Chokehold maneuver Other (describe) Was the patient smothered? No Yes (describe) Was the patient shaken during the incident? No Yes (describe) Was the patient s head pounded against any object during the incident? No Yes (describe) Was the patient slapped, kicked, or bitten anywhere? No Yes (describe) Was the assailant wearing any jewelry on hands or wrists? Unknown No Yes (describe) Describe the neck pressure during strangulation on a 0 10 scale (0=no pressure and 10=crushing pressure): What is the measurement of the patient s neck circumference? Was the patient sexually assaulted? No Yes What was the patient thinking during the strangulation? _ What did the assailant say before, during, or after the strangulation? _ Describe mannequin demonstration (where applicable) _
2 Signs/Symptoms of The following signs/symptoms should be asked about, assessed for and documented in writing, with body mapping, and by photo-imaging (if applicable). Check ALL that apply. Signs Face Red, flushed Cuts Red, flushed Cuts Red, flushed Cuts Red, flushed Cuts Eyes : Conjunctiva Eyelids Upper right Lower right Upper left Lower left : Conjunctiva Eyelids Upper right Lower right Upper left Lower left : Conjunctiva Eyelids Upper right Lower right Upper left Lower left : Conjunctiva Eyelids Upper right Lower right Upper left Lower left Subconjunctival hemorrhage Subconjunctival hemorrhage Subconjunctival hemorrhage Subconjunctival hemorrhage Ptosis Ptosis Ptosis Ptosis Vascular congestion Vascular congestion Vascular congestion Vascular congestion Nose Bleeding Bleeding Bleeding Bleeding
3 Signs Mouth Ears Head/scalp Neck/under Chin Shoulders Swollen tongue Swollen lips Cut Bleeding from ear canal Auditory changes on scalp Pulled hair Contusions Ligature marks Swollen tongue Swollen lips Cut Bleeding from ear canal Auditory changes on scalp Pulled hair Contusions Ligature marks Swollen tongue Swollen lips Cut Bleeding from ear canal Auditory changes on scalp Pulled hair Contusions Neck pain Ligature marks Swollen tongue Swollen lips Cut Bleeding from ear canal Auditory changes on scalp Pulled hair Contusions Ligature marks
4 Signs Chest Symptoms Behavioral Neurological Throat/Voice Agitation Combative Anxiety Memory disruption Confusion LOC Uncertain if LOC of urine of feces Seizures Headache Dizzy Fainting Tinnitus Visual changes Dysphagia Odynophagia (pain) Dysphasia Aphasia Drooling or Inability to swallow Throat pain Hoarse/Raspy Agitation Combative Anxiety Memory disruption Confusion LOC Uncertain if LOC of urine of feces Seizures Headache Dizzy Fainting Tinnitus Visual changes Dysphagia Odynophagia (pain) Dysphasia Aphasia Drooling or Inability to swallow Throat pain Hoarse/Raspy Agitation Combative Anxiety Memory disruption Confusion LOC Uncertain if LOC of urine of feces Seizures Headache Dizzy Fainting Tinnitus Visual changes Dysphagia Odynophagia (pain) Dysphasia Aphasia Drooling or Inability to swallow Throat pain Hoarse/Raspy Agitation Combative Anxiety Memory disruption Confusion LOC Uncertain if LOC of urine of feces Seizures Headache Dizzy Fainting Tinnitus Visual changes Dysphagia Odynophagia (pain) Dysphasia Aphasia Drooling or Inability to swallow Throat pain Hoarse/Raspy
5 Symptoms Respiratory Stridor Coughing Hyperventilation Respiratory distress Hemoptysis Inability to tolerate supine position Stridor Hoarseness Hyperventilation Respiratory distress Hemoptysis Inability to tolerate supine position Stridor Hoarseness Hyperventilation Respiratory distress Hemoptysis Inability to tolerate supine position Stridor Hoarseness Hyperventilation Respiratory distress Hemoptysis Inability to tolerate supine position Gynecological Genitourinary Gastrointestinal Vaginal Pregnant Contractions FHR Dysuria Nausea Vomiting Anal/rectal Abdominal pain (scale 0-10) Vaginal Pregnant Contractions FHR Dysuria Nausea Vomiting Anal/rectal Abdominal pain (scale 0-10) Vaginal Pregnant Contractions FHR Dysuria Nausea Vomiting Anal/rectal Abdominal pain (scale 0-10) Vaginal Pregnant Contractions FHR EDC Dysuria Nausea Vomiting Anal/rectal Abdominal pain (scale 0-10)
6 Please indicate all injuries checked above on the body maps below.
7 Please indicate all injuries checked above on the body maps below. Photo-documentation of findings: Yes No Notes
8
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2. Approx. Date of Onset: 3. Approx. Date of Onset:
Healthy Balance Lisa A. Dulac, L.Ac. Acupuncture Patient Intake Form Present Health Concerns: Please list your most important health concerns in order of their significance. 1. Approx. Date of Onset: 2.
RHEUMATOLOGY PATIENT HISTORY FORM
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Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
Primary Chief Complaint 1. Location 2. When did this begin? 3. How did this begin?
Name Date These questions that you are about to answer are very important for the Doctor. They will enable the doctor make a complete and diagnosis, and provide medical documentation (if needed)to your
Joseph S. Weiner, MD, PC Patient History Form
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Acupuncture & Herbal Therapies
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