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MEDICO-LEGAL CERTIFICATE<br />

DEMOGRAPHIC DATA<br />

PATIENT’S NAME AGE DOB SEX<br />

PATIENT’S ADDRESS<br />

CIVIL STATUS OCCUPATION NATIONALITY<br />

REQUESTING PARTY<br />

PLACE, TIME AND<br />

DATE OF EXAM<br />

� Acute Evidentiary Examination (within 72 Hours of incident) � Non-Acute Examination<br />

FINDINGS<br />

General Physical Findings<br />

HEIGHT WEIGHT<br />

GENERAL SURVEY<br />

MENTAL STATUS<br />

PERTINENT PHYSICAL<br />

FINDINGS/ PHYSICAL<br />

INJURIES<br />

EXTERNAL GENITALIA<br />

URETHRA AND<br />

PERIURETHRAL AREA<br />

PERIHYMENAL AREA AND<br />

FOSSA NAVICULARIS<br />

HYMEN<br />

PERINEUM<br />

DISCHARGE<br />

INTERNAL AND SPECULUM<br />

EXAMS<br />

ANAL EXAMINATION<br />

FORENSIC EVIDENCE AND<br />

LABORATORY RESULTS<br />

ANO-GENITAL EXAMINATION<br />

DIAGNOSTICS AND EVIDENCE GATHERING<br />

IMPRESSIONS

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