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Document ID: FR-12-0034-1.0 Page 1 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
Victorian Institute of Forensic Medicine
Sexual Assault Examination Record
Confidential
This document is intended as a guide to the forensic medical examination and should be used at the examiner’s discretion.
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 2 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
CLINICAL FORENSIC MEDICAL EXAMINATION
EXAMINERS NAME:
Forensic Medical Officer
Forensic Registrar
Forensic Nurse Examiner
Other:
………………………………………………………
Place FMEK Label Here
Date of examination:
Time Case Commenced:
Time Case Concluded:
PATIENT DETAILS
Name:
Date of birth:
Gender: M F
Contact Phone Number:
EXAMINATION DETAILS
Location
Monash Medical Centre
Royal Women’s Hospital
Maroondah
Austin Hospital
Sunshine
Frankston
Regional CCU (Specify):
…………………………………………………………
Other:
…………………………………………………………
INFORMANT DETAILS
Rank & Name
DX:
Station/SOCIT:
……………………………………..………….
Phone:
……………………………………………..….
OBSERVER DETAILS
1. Name:……………………………………….
Role:………………………………………….
Stages Present:
History Examination Both
2. Name:…………………………………………........
Role:………………………………………………….
Stages Present:
History Examination Both
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 3 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
CONSENT FOR MEDICO-LEGAL CONSULTATION1
The Forensic Examiner in this case has explained to me the procedures of examination,
evidence collection and release of findings to Police and/or in Courts.
I …………………………………………………………..(Insert patient’s name), agree to the following:
(Mark each as appropriate)
Medical Examination (including
examination of the genitalia and
anus)
Providing a verbal and/or written report
to Police.
Collection of specimens for medical
investigations Collection of specimens for forensic
investigations
Photography Non-identifying data can be used for
quality assurance, teaching and
research activities.
A phone call from the Forensic Examiner for follow-up purposes. Best time of day to call:
….…… : ……….. am/pm
- AND –
Authorise the Forensic Examiner to release the collected forensic specimens to Police.
Patient/Guardian Signature Date: ……./…..…. /………
Examiner’s Signature Date: ……./…..…. /………
Patient unable to provide consent.
Forensic Medical Examination
deferred.
Details:
Patient unable to provide consent.
Consent obtained from:
.…………………………………………………...
Details:
Patient declined Forensic Examination on this occasion.
Details:
1 The person must be provided with a detailed explanation of what is proposed during the consultation so they
are able to give informed consent. This should include the examination procedures (particularly details of any
proposed examination of the genitalia or anus), photography, specimen collection, any treatment, and the
release of information to other parties. This should be provided in a language that is readily understood by the
patient.
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 4 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
CASE DETAILS
SUMMARY FROM POLICE (or others)
Details provided by (name):
RELEVANT PAST MEDICAL HISTORY
GYNAECOLOGICAL HISTORY
Last menstrual period? …………………………
Was patient menstruating at the time of the assault? Yes No Unsure/Not asked
Is the patient pregnant? Yes No Unsure/Not asked
Contraception? (Type?) …………………… ..…………. Yes No Unsure/Not asked
History of genital trauma/pathology/surgery Yes No Unsure/Not asked
…………………………………………………………………………………………………………………………………
OTHER RELEVANT MEDICAL/SURGICAL/PSYCHIATRIC HISTORY
MEDICATIONS/IMMUNISATIONS
Hepatitis B Tetanus
Allergies:
.................................................................................
.................................................................................
Medications(Specify):
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
CONSUMED DRUGS and/or ALCOHOL (Type, amount, timing)
Alcohol
Drugs
(Specify):
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 5 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
HISTORY OF ASSAULT
Location:
DATE
TIME
Own Home Other’s Home
…… /……. /……
….. : …. am/pm Car Outdoors
Venue e.g.
(Nightclub)
Other (Specify):
……………………………………………………………………………
……………………………………………………………………………
…………………
……………..…..
Details from the patient (or if other specify who):
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 6 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
Extra Notes ………………………………………………………………………………………………………………………
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Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 7 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
ANOGENITAL CONTACT SUMMARY
History of Vaginal Contact or Penetration Yes No Unsure/Not asked
Vaginal Pain Yes No Unsure/Not asked
Vaginal Bleeding Yes No Unsure/Not asked
Urinary Symptoms Yes No Unsure/Not asked
Vaginal Symptoms
Yes No Unsure/Not asked
Summary Description:
History of Anal Contact or Penetration
Yes No Unsure/Not asked
Anal Pain Yes No Unsure/Not asked
Anal Bleeding Yes No Unsure/Not asked
Bowel Symptoms Yes No Unsure/Not asked
Summary Description:
(Include details of pre and post assault bowel actions)
History of Oral Contact or Penetration Yes No Unsure/Not asked
Oral Symptoms
Yes No Unsure/Not asked
Summary Description:
EJACULATION:
Vagina Yes No Unsure
Other body site Yes No Unsure (please specify):
Anal Yes No Unsure
Oral Yes No Unsure
Condom used Yes No Unsure Lubricant used Yes No Unsure
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 8 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
POST-ASSAULT
Pre-assault Intercourse within previous week Yes No Not asked
Time: :
Who:
Date: ………/……… /………
Post-assault Intercourse Yes No Not asked
Time: :
Who:
Date: ………/……… /………
OTHER
History of Bite/s Yes No
Not asked/Not answered
Site(s):
Other Trauma (Specify):
History of trauma to Neck
Loss of consciousness
Breathing difficulties
Pain on swallowing
Sore throat
Hoarse voice
Referral to Emergency
Department
Yes No Unsure
Yes No Unsure
Yes No Unsure
Yes No Unsure
Yes No Unsure
Yes No Unsure
Yes No
CURRENT SYMPTOMS
POST-ASSAULT DETAILS
Brushed Teeth Yes No N/A
Rinsed Mouth Yes No N/A
Tampon/Pad Used Yes No N/A
Bathed/Showered Yes No N/A
Changed Clothes Yes No N/A
Cleaned Clothes Yes No N/A
Clothes given to police Yes No N/A
EXAMINATION
APPEARANCE: (Place findings here. Use body charts for diagrams. Indicate any sites not examined)
Signs of Alcohol/drug effect
Behaviour
Cognitive functioning
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 9 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
Not Examined Nil Injury Noted
Right Left
Right Left
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 10 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
Not Examined Nil Injury Noted
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 11 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
Not Examined Nil Injury Noted
Right Left
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 12 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
Not Examined Nil Injury Noted
Left Right
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 13 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
Not Examined Nil Injury Noted
Right
Inner Outer
Left
Outer Inner
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 14 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
Speculum Examination Conducted Yes No
Proctoscopy Conducted Yes No
Not Examined Nil Injury Noted
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 15 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
PHOTOGRAPHS
Taken By :
Self Other (Specify) Not Taken
TOXICOLOGY
Toxicology samples taken: Yes (Complete Toxicology Form) No
MEDICATION PROVIDED
(Ensure script written and hospital record completed)
Emergency contraception Yes No
Azithromycin Yes No
Hep B immunoglobulin/immunisation Yes No
NPEP Yes No
Other (specify):
HOSPITAL PATHOLOGY COLLECTED
Please specify:
REFERRAL
GP
Emergency Department
Letter written
Psychiatric Services
Sexual Assault Follow-up Clinic
Other: ……………………………………………………
Referral Contact:
Treatment and Advice:
LIMITATIONS TO EXAMINATION OR OPINION
Patient Location Equipment
Details:
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 16 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
Proctoscopy Conducted Yes No
Not Examined Nil Injury Noted
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 17 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
This page is left blank intentionally.
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 18 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
FORENSIC SAMPLES Date of assault: …………………….……….
Time of assault:……………………………..
Examiner:……………………….……..……
Date of examination:……………….…………
Time:……………..…………….……………..
FMEK #:……………………………………..
DATA AVAILABLE
Number of offenders:………………
Known Acquaintance
Unknown Other: …………………
Vaginal penetration
Finger Penis
Ejaculation Other: …………
Anal Penetration
Finger Penis
Ejaculation Other: …………………
Oral Penetration
Penis Ejaculation
Other site of ejaculation
……………………………………………..…..
…………………………………………………
Condom
Lubricant
Saliva suspected (kissed, licked or bitten?)
Site:…………………………………………….
…………………………………………………
…………………………………………………
Forensic Dentist consulted
Showered / washed
Suspected Drug Facilitated Sexual Assault
Specific details regarding clothing? (ie washed post
assault, location of marks/stains etc)
…………………………………………….……
………………………………….………………
Sexual Contact prior to the assault: (<7 days)
………..……………………………………………
………………………………………….
……………………………………………….
COMPARISON SAMPLES
2 x Buccal swabs/blood for DNA:…................. (PLEASE KEEP REFERENCE SWAB SEPARATE FROM OTHER SAMPLES WHEN HANDING OVER TO POLICE (ie put in separate
labelled envelope)
Hair: Head/Pubic:…………….......................
SAMPLES
Underpants: ...........................................
Clothing ( bags) contents: ...........................................
...........................................
Drop sheet: ...........................................
Tampon/Pad: ...........................................
Condom: ...........................................
Other: ...........................................
...........................................
BODY EVIDENCE Oral swab and slide: ...........................................
Mouth rinsings (20 ml in a
sterile container): ...........................................
Foreign material on body Site: ...........................................
Skin swab(s) / slide for
semen/saliva [wet / dry] Site: ...........................................
Skin swab(s) / slide for
semen/saliva [wet / dry] Site: ......................../..................
Skin swab(s) / slide for
semen/saliva [wet / dry] Site: ......................../..................
Fingernail scrapings -
RIGHT/LEFT: ......................./...................
Hair Samples: ...........................................
ANO-GENITAL EVIDENCE
Foreign material: ...........................................
Vulval swab(s) and slide(s)
Number: ...........................................
High vaginal swab(s) and
slide(s) Number: ...........................................
Endocervical swab(s) and
slide(s) Number: ...........................................
Penile shaft swab(s) and
slide(s) Number: ......................../..................
Penile glans swab(s) and
slide(s) Number: ......................../..................
Anal swab(s) and slide (s)
Number: ......................./...................
Other (specify): ...........................................
DRUG SCREENING - complete separate form
Blood for alcohol and drugs
(VIFM kit/other): ...........................................
Urine for drugs: ...........................................
OTHER DETAILS OF RELEVANCE:…………………………………………………………………………….
…………………………………………………………………………………………………….
HANDED TO:
TIME & DATE:
Signed:
Forensic Medical Examination Record (Sexual Assault)
Name:…………………………………………………......DOB:………………
Document ID: FR-12-0034-1.0 Page 17 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
FORENSIC SAMPLES Date of assault: …………………….……….
Time of assault:……………………………..
Examiner:……………………….……..……
Date of examination:……………….…………
Time:……………..…………….……………..
FMEK #:……………………………………..
DATA AVAILABLE
Number of offenders:………………
Known Acquaintance
Unknown Other: …………………
Vaginal penetration
Finger Penis
Ejaculation Other: …………
Anal Penetration
Finger Penis
Ejaculation Other: …………………
Oral Penetration
Penis Ejaculation
Other site of ejaculation
……………………………………………..…..
…………………………………………………
Condom
Lubricant
Saliva suspected (kissed, licked or bitten?)
Site:…………………………………………….
…………………………………………………
…………………………………………………
Forensic Dentist consulted
Showered / washed
Suspected Drug Facilitated Sexual Assault
Specific details regarding clothing? (ie washed post
assault, location of marks/stains etc)
…………………………………………….……
………………………………….………………
Sexual Contact prior to the assault: (<7 days)
………..……………………………………………
………………………………………….
……………………………………………….
COMPARISON SAMPLES
2 x Buccal swabs/blood for DNA:…................. (PLEASE KEEP REFERENCE SWAB SEPARATE FROM OTHER SAMPLES WHEN HANDING OVER TO POLICE (ie put in separate
labelled envelope)
Hair: Head/Pubic:…………….......................
SAMPLES
Underpants: ...........................................
Clothing ( bags) contents: ...........................................
...........................................
Drop sheet: ...........................................
Tampon/Pad: ...........................................
Condom: ...........................................
Other: ...........................................
...........................................
BODY EVIDENCE Oral swab and slide: ...........................................
Mouth rinsings (20 ml in a
sterile container): ...........................................
Foreign material on body Site: ...........................................
Skin swab(s) / slide for
semen/saliva [wet / dry] Site: ...........................................
Skin swab(s) / slide for
semen/saliva [wet / dry] Site: ......................../..................
Skin swab(s) / slide for
semen/saliva [wet / dry] Site: ......................../..................
Fingernail scrapings -
RIGHT/LEFT: ......................./...................
Hair Samples: ...........................................
ANO-GENITAL EVIDENCE
Foreign material: ...........................................
Vulval swab(s) and slide(s)
Number: ...........................................
High vaginal swab(s) and
slide(s) Number: ...........................................
Endocervical swab(s) and
slide(s) Number: ...........................................
Penile shaft swab(s) and
slide(s) Number: ......................../..................
Penile glans swab(s) and
slide(s) Number: ......................../..................
Anal swab(s) and slide (s)
Number: ......................./...................
Other (specify): ...........................................
DRUG SCREENING - complete separate form
Blood for alcohol and drugs
(VIFM kit/other): ...........................................
Urine for drugs: ...........................................
OTHER DETAILS OF RELEVANCE:…………………………………………………………………………….
…………………………………………………………………………………………………….
HANDED TO:
TIME & DATE:
Signed:
FMEK COPY
Document ID: FR-12-0034-1.0 Page 18 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
…../…../……….
Dear Doctor,
RE: ___________________________________________________
Thank you for the ongoing care of this patient who was allegedly sexually assaulted ___days
ago. She/he underwent a forensic medical examination on ……../……/……...
Emergency contraception (POSTINOR-2) was given Yes No
Hepatitis B Immunoglobulin/Vaccination was given Yes No
There are injuries requiring follow-up Yes No
Further comments (including other medications given) -
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
She/he may require an STI screen in approximately 2 weeks. If urine/blood toxicology was
taken we will notify your patient of the result.
If a sexually transmitted infection or a pregnancy may have resulted from this sexual assault
would you kindly send me a copy of the results with your patient's permission?
Yours sincerely,
………………………………………………………..
Victorian Institute of Forensic Medicine Ph: (03) 9684 4480
Fx: (03) 9684 4481
PATIENT COPY
Document ID: FR-12-0034-1.0 Page 18 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
…../…../……….
Dear Doctor,
RE: ___________________________________________________
Thank you for the ongoing care of this patient who was allegedly sexually assaulted ___days
ago. She/he underwent a forensic medical examination on ……../……/……...
Emergency contraception (POSTINOR-2) was given Yes No
Hepatitis B Immunoglobulin/Vaccination was given Yes No
There are injuries requiring follow-up Yes No
Further comments (including other medications given) -
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
…………………………………………………………………………………………………
She/he may require an STI screen in approximately 2 weeks. If urine/blood toxicology was
taken we will notify your patient of the result.
If a sexually transmitted infection or a pregnancy may have resulted from this sexual assault
would you kindly send me a copy of the results with your patient's permission?
Yours sincerely,
………………………………………………………..
Victorian Institute of Forensic Medicine Ph: (03) 9684 4480
Fx: (03) 9684 4481
Document ID: FR-12-0034-1.0 Page 19 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
REQUEST FOR TOXICOLOGY (This form should be sent with the samples to VIFM via the attending police officer)
PATIENT NAME:…………………………DOB:…/……/……CONTACT PHONE NO. …...…….
CLINICIAN NAME: (Please Print) ……………………………………………………………………
□ Clinical Forensic Medicine □ VFPMS
□ Other. (Address) ………………………… ……………………………………………………….
………………………………………………………………. PH:…….……………………...
SAMPLE(S) COLLECTED (Blood & urine if < 24hrs OR Urine only if > 24 hrs since exposure to drug)
□ URINE (25mls in sterile container) Collection date / / Time: ……………hrs
□ BLOOD (10ml in fluoride/oxalate tube) Collection date / / Time: ……...…….hrs
REASON FOR COLLECTION (Tick those applicable – may be multiple)
□ Suspected drug administration by covert means (eg ‘drink spiking’)
□ Known drug administration /consumption
□ Suspected sexual assault whilst under influence of drugs/alcohol
□ Other (Specify) ………………………………………………………………………………………..
SUSPECTED DRUG (S)
Is a specific drug(s) suspected/sought? □ No □ Yes
Name/s: ……………………………………………………........................................................................
Specific symptoms/ signs indicating drug effect? (Observed or Account Provided)
……………………………..………………………………………………………..……………………..
……………………………………………………………………………………………………………..
………………………………………………………………………………………………..……………
KNOWN DRUG CONSUMPTION (In last two weeks including Prescription, OTC, Party, Illicit etc)
DRUG/MEDICATION
NAME
AMOUNT/DOSE LAST DOSE-
DATE/TIME
Has the patient used cannabis in the last 2 weeks? □ Yes □ No □ Unknown / Undetermined
KNOWN ALCOHOL CONSUMPTION (In last 24 hours)
TYPE / NAME AMOUNT DOSE DATE / TIME
Time of last alcoholic drink: …………………………………. ……………………………………
□ NIL ALCOHOL CONSUMED □ UNKNOWN IF ALCOHOL CONSUMED
CONFIDENTIAL
PATIENT NOTIFIED: REPORT SENT TO POLICE:
BY: BY:
DATE: DATE:
Further information: …………………………………………………………………………..…………..
…………………………………………………………………………………………………….................
……………………………………………………………………………………………………...
S…………
Document ID: FR-12-0034-1.0 Page 19 of 19
Date Effective : 01/03/2012 AUTHORISED COPY OF FORM Next Review Date : 01/03/2014
REQUEST FOR TOXICOLOGY (This form should be sent with the samples to VIFM via the attending police officer)
PATIENT NAME:…………………………DOB:…/……/……CONTACT PHONE NO. …...…….
DOCTOR’S NAME: (Please Print) ……………………………………………………………………
□ Clinical Forensic Medicine □ VFPMS
□ Other. (Address) ………………………… ……………………………………………………….
………………………………………………………………. PH:…….……………………...
SAMPLE(S) COLLECTED (Blood & urine if < 24hrs OR Urine only if > 24 hrs since exposure to drug)
□ URINE (25mls in sterile container) Collection date / / Time: ……………hrs
□ BLOOD (10ml in fluoride/oxalate tube) Collection date / / Time: ……...…….hrs
REASON FOR COLLECTION (Tick those applicable – may be multiple)
□ Suspected drug administration by covert means (eg ‘drink spiking’)
□ Known drug administration /consumption
□ Suspected sexual assault whilst under influence of drugs/alcohol
□ Other (Specify) ………………………………………………………………………………………..
SUSPECTED DRUG (S)
Is a specific drug(s) suspected/sought? □ No □ Yes
Name/s: ……………………………………………………........................................................................
Specific symptoms/ signs indicating drug effect? (Observed or Account Provided)
……………………………..………………………………………………………..……………………..
……………………………………………………………………………………………………………..
………………………………………………………………………………………………..……………
KNOWN DRUG CONSUMPTION (In last two weeks including Prescription, OTC, Party, Illicit etc)
DRUG/MEDICATION
NAME
AMOUNT/DOSE LAST DOSE-
DATE/TIME
Has the patient used cannabis in the last 2 weeks? □ Yes □ No □ Unknown / Undetermined
KNOWN ALCOHOL CONSUMPTION (In last 24 hours)
TYPE / NAME AMOUNT DOSE DATE / TIME
Time of last alcoholic drink: …………………………………. ……………………………………
□ NIL ALCOHOL CONSUMED □ UNKNOWN IF ALCOHOL CONSUMED
CONFIDENTIAL
PATIENT NOTIFIED: REPORT SENT TO POLICE:
BY: BY:
DATE: DATE:
Further information: …………………………………………………………………………..…………..
…………………………………………………………………………………………………….................
……………………………………………………………………………………………………...
S…………
POLICE COPY