Exam - DVNE

Exam Information & Patient Demographics
Date of Exam:
Exam start time:*
DVNE Nurse performing exam:*

First NameLast Name
Location of exam:*
"Other" location:*
Nurse observer?*
Nurse observer:*

First NameLast Name
Patient name:*

First Name Middle InitialLast Name
Alias(s), maiden name, etc.:*
Date of birth:*

MonthDayYear
Age:*
Gender:*
Race:*
Primary language:*
Interpreter name & agency:*
Patient phone number:*

Area CodePhone Number
Patient address:*

Street Address

Street Address Line 2

CityState

Zip Code
If address/phone is not patient's, indicate here:
Nurse Notes/Comments:

Medical Information
Primary medical concern today related to the assault::*
Tetanus immunization status:*
Current birth control method:*
Last menstrual period:

MonthDayYear
Date
Currently experiencing pain?*
Location & pain scale (1/10):*
Recent illness or given birth with the last 2-4 weeks?*
Describe:*
Allergies to medication?*
Medication allergies:*
Currently taking any medication(s)?*
Current medication names:*
Past medical problems/diagnosis?*
Past medical history:*
Previous surgeries?*
Surgical history:*
Pregnant?*
Pregnancy test:*
Prenatal care:*
Due date:*

MonthDayYear
Date
Have you noticed any of the following since the assault?*
Nurse Notes/Comments:

Assault Details
Date of assault:*
Approximate time of assault:
Relationship to assailant at time of assault:*
Do you live with the assailant?*
Assailant name:*

First NameLast Name
Alias(s), nickname, street name, etc.:
Specific location of assault:*
City of assault:*
County of assault:*
Medical attention/treatment post assault?*
Describe medical attention and/or treatment:*
ASSAILANT Drug/alcohol at time of assault?*
Describe ASSAILANT Use:*
PATIENT Drug/alcohol at time of assault?*
Describe PATIENT Use:*
Patient Narrative of Assault
Patient's orientation, affect, & appearance:*
Patient's orientation, affect, & appearance:*
Patient states:*
Patient signature confirms the above narrative is a true an accurate reflection of their statements:*

Clear
Nurse Notes/Comments:

Details of CURRENT Physical Assault

Check all that apply for physical abuse during current assault, by this assailant:*

	Number of times:	Briefly describe (where, how, etc.):
Threats of Harm/ Intimidated
Pushed
Grabbed
Slapped
Punched
Struck with Object
Hit by Thrown Object
Bit
Pinched
Burned
Kicked
Restrained/Held Down
Tied/Bound
Weapon(s) Present; Intimidated/Threatened
Weapon(s) Used
Other:

Strangulation?*
If yes, see details on Strangulation Assessment
Were you hit in the head, or was your head hit by, or against, a hard object/surface during the assault?*
Describe head injury:*
Symptoms patient reports during/right after assault due to head injury:*
Symptoms patient reports NOW due to head injury:*
Sexual assault, abuse, and/or coercion?*
Describe sexual assault/abuse and/or coercion:*
VAGINAL penetration?*
Vagina penetrated with:*
Describe object:*
ANAL penetration?*
Anus penetrated with:*
Describe object:*
SANE Exam:*
Nurse Notes/Comments:

Other Type(s) of Abuse Experienced
Have you experienced any of the following non-physical types of abuse by this assailant?
Verbal and/or Emotional:*
When:*
Describe Verbal and/or Emotional:*
Isolation and/or Seclusion:*
When:*
Describe Isolation and/or Seclusion:*
Stalking and/or Harassment:*
When:*
Describe Stalking and/or Harassment:*
Economic and/or Financial:*
When:*
Describe Economic and/or Financial:*
Witnesses to Assault
Any minor children living in the home?*
How many?*
Child Details (1):*
Child Details (2):*
Child Details (3):*
Child Details (4):*
Did anyone else witness the assault?*
Witness(es) name(s) and relationship(s):*
Nurse Notes/Comments:

Strangulation Assessment
Provide a brief, detailed narrative of just the strangulation(s):*
Physical surroundings during strangulation(s):*
How many times were you strangled?*
Over what period of time did the strangulation(s) occur (how long between each strangulation)?*
How/what did you feel PHYSICALLY during the strangulation(s)?*
Symptom(s) patient reports were experienced during strangulation(s):*
Symptom(s) patient reports were experienced immediately or soon after strangulation(s):*
Symptom(s) patient reports now:*
Baseline symptom(s) patient reports before strangulation:*
Strangulation Details (1):*
Strangulation Details (2):*
Strangulation Details (3):*
Strangulation Details (4):*
Other than strangulation(s), did any of the following occur, causing you difficulty or the inability to breathe?*
Describe:*
Nurse Notes/Comments:

Strangulation Assesssment Continued
How much force/pressure did assailant use overall during strangulation(s)? (1/10)*
1=minimal 10=maximum
How much pain did strangulation(s) cause you overall? (0/10)*
0=none, 10=maximum
Are you having neck/throat pain now?*
Rate pain (1/10)?*
1=minimal 10=worst
Were you lifted/picked up by your neck?*
Were you shaken or whipped back and forth by your neck (whiplash/rag-doll)?*
Were you held up against a wall or pushed down into the ground/floor by your neck?*
Were you, or the assailant, wearing anything that could have caused you injury/markings to your neck or surrounding area(s)?*
Describe:*
Did you physically attempt to stop the strangulation(s)?*
Describe:*
Did you injure yourself in any way during the strangulation(s)?*
Describe:*
Did the assailant say anything during the strangulation(s)?*
Describe what assailant said:*
What caused the strangulation(s) to end?*
Nurse Notes/Comments:

History of Prior Physical Abuse by This Assailant
Select types of abuse previously experienced by this assailant?*
Provide any pertinent information about previous abuse:*
Have you received medical treatment for any of the previous physical abuse?*
Do you have any untreated injuries or medical concerns related to the previous abuse?*
Provide details for previous strangulations:*
Prior to this assault, has this assailant ever caused you to lose, or have an alteration in, consciousness, by strangulation or other means?*
Provide details for OTHER:*
Filed VPO against this assailant in the past?*
Describe previous sexual assault, abuse, and/or coercion:*
Received a SANE Exam?*
Nurse Notes/Comments:

Physical Findings
Strangulation Specific Findings:*
Describe other:*
Patient's Current Neck Circumference(CM):*
Head:*
Face:*
Eye(s):*
Mouth:*
Neck:*
Chest/Breast(s):*
Nurse Notes/Comments:

Physical Findings
Abdomen/Back (Torso):*
Arm(s):*
Hand(s):*
Leg(s):*
Feet:*
Other:*
Select Injury Diagrams to Display:*

HeadF/B Full BodyL/R Full BodyEyesTorsoHandsFeet
Nurse Notes/Comments:

Injury Diagram: Head, Face, Mouth - Annotate Injuries/Abnormalities
Nurse Notes/Comments:

Injury Diagram: Eyes - Annotate Injuries/Abnormalities
Nurse Notes/Comments:

Injury Diagram: F/B Full Body - Annotate Injuries/Abnormalities
Nurse Notes/Comments:

Injury Diagram: L/R Full Body - Annotate Injuries/Abnormalities
Nurse Notes/Comments:

Injury Diagram: Torso - Annotate Injuries/Abnormalities
Nurse Notes/Comments:

Injury Diagram: Hands - Annotate Injuries/Abnormalities
Nurse Notes/Comments:

Injury Diagram: Feet - Annotate Injuries/Abnormalities
Nurse Notes/Comments:

Discharge Planning
CPS Report Info:*
Referrals and Consultations:*
Education & instructions provided on:*
Other Education/Instructions:*
Nursing Diagnosis:*
Other diagnosis:*
Additional Information:*
Evidence Collection
Equipment Used During Exam:*
Evidence Collected:*
Other evidence:*
Describe clothing:*
Forensic photos taken during exam:*

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Exam Reporting/Release Status:*
Non-Report - YWCA Case #:*
Reporting Case #:*
Law Enforcement Agency to Release to:*
Detective/Officer:*
Nurse Signature:*

Clear
Exam end time:*
Length of Exam:
Nurse Notes/Comments:
Should be Empty:

	Yes	No
1. Has the physical violence increased in severity or frequency over the past year?
2. Does he own a gun?
3. Have you left him after living together during the past year?
a. If you have never lived with him, check "yes" here
4. Is he unemployed?
5. Has he ever used a weapon against you or threatened you with a lethal weapon?
*Was the weapon a knife or gun?
6. Does he threaten to kill you?
7. Has he avoided being arrested for domestic violence?
8. Do you have a child that is not his biological child?
9. Has he ever forced you to have sex when you didn't wish to do so?
10. Does he ever try to choke/strangle you or cut off your breathing?
a. If yes, has he done it more than once, or did it make you pass out, black out, or make you dizzy?
11. Does he use illegal drugs? (I mean "uppers" or amphetamines, speed, angel dust, cocaine, "crack, street drugs or mixtures.)
12. Is he an alcoholic or problem drinker?
13. Does he control most or all of your daily activities? For instance: Tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car?
*If he tries but you do not let him, check "yes" here.
14. Is he violently and constantly jealous of you? (For instance, say "If I can't have you, no one can"?)
15. Have you ever been beaten by him while you were pregnant?
*If you have never been pregnant by him, check "yes" here.
16. Has he ever threatened or tried to commit suicide?
17. Does he threaten to harm your children?
18. Do you believe he is capable of killing you?
19. Does he follow or spy on you, leave threatening notes or messages, destroy your property, or call you when you don't want him to?
20. Have you ever threatened or tried to commit suicide?

Exam Information & Patient Demographics

Medical Information

Assault Details

Patient Narrative of Assault

Details of CURRENT Physical Assault

Other Type(s) of Abuse Experienced

Have you experienced any of the following non-physical types of abuse by this assailant?

Witnesses to Assault

Strangulation Assessment

Strangulation Assesssment Continued

History of Prior Physical Abuse by This Assailant

Physical Findings

Physical Findings

Discharge Planning

Evidence Collection