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WellSpan Health Forensic Medical Record
York Hospital
Gettysburg Hospital
Adult/Adolescent
Form 4431 5/2012
WellSpan Health Forensic Medical Record
York Hospital
Gettysburg Hospital
Adult/Adolescent
Form 4431 5/2012
Review of Systems
Reviewed in Emergency Department Record. See ED Record for Data.
Skin



Negative
Rash
Other __________________________________________
Eyes




Negative
Discharge
Recent visual changes
Other ___________________________________________
ENT
 Negative
 Ear pain R L
 Sore throat
 Nasal congestion
 Dental pain
 Other ___________________________________________
Genitourinary
 Negative
 Pain with urination
 Vaginal discharge:________
 Other ___________________________________________
Neurological
 Negative
 Headache
 Mental status changes
 Other __________________________________________
Immunization
 Up to date
 Last Tetanus__________________________
 Hepatitis B
Allergy Problems  Yes
No
 Medication Allergies
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
 Other
_______________________________________________
_______________________________________________
_______________________________________________
Cardiovascular
 Negative
 Chest pain
 Palpitations
 Other _______________________________
Pulmonary
 Negative
 Shortness of breath
 Cough
 Wheezing
 Other _______________________________
Gastrointestinal
 Negative
 Nausea/vomiting
 Constipation/diarrhea
 LBM:________
(last bowel movement)
 Other _______________________________
Musculoskeletal
 Negative
 Trauma
 Muscle/Joint pain
 Other _______________________________
Hematologic
 Negative
 Easy bruising
 Recent epistaxis (nosebleed)
 Heavy menstrual bleeding
 Prolonged bleeding after surgical procedure
 Other _______________________________
Immune Disorders
 Yes ________________________________
 No
Current Medications:
 _________________________________
Initials________/Date_______
130 Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________
Page 4 of 28
Patient History/Initial Assessment
Triage Vital Signs: T_______ P_______ RR _______ BP ______ Time Recorded _____________
Domestic Violence Screen  Verbalized Yes  Verbalized No
•
Pain Present?
•
Where_____________________________________________________________________________________
•
Scale______________________________________________________________________________________
•
Onset______________________________________________________________________________________
•
Quality/Type________________________________________________________________________________
Race of victim:
 Yes
 Done at Triage
 No
 African American  Asian  Caucasian  Hispanic White
 Hispanic Black  Native American  Other:_________________________________________
Victim’s Hair Color:
Overall Appearance (Torn clothing, disheveled…):_________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Behavioral Observations/Affect/Mood:__________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Suicidal Ideations:  No  Yes
Initials________/Date_______
If yes, crisis and Emergency Physician consults done  Yes
Page 5 of 28
Appendices
131