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Part 4 Forensic Rape Exam 2000_1

Part 4 Forensic Rape Exam 2000_1

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Published by: SilenceIsOppression on Nov 01, 2010
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09/26/2013

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,I
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STEP 1AUTHORIZATION FOR COLLECTION AND RELEASEOF EVIDENCE AND INFORMATION
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freely consent toallow
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M.D., his medical andnursing assistants and associates to conduct an examination to collect evidence concerningan alleged sexual assault. This procedure has been fully explained to me and Iunderstand that this examination will include tests for the presence of sperm and venerealdisease, as well as clinical observation for physical evidence of penetration of or injuryto my person, or both, and the collection of other specimens and blood samples forlaboratory analysis.I fully understand the nature of the examination and the fact that medical informationgathered by this means may be used as evidence in a court of law or in connection withenforcement of public health rules and law.I do;:lJ do not
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authorize the hospital and its agents to release the laboratoryspecimens, medical records and related information pertinent to this incident, includingany photographs, to the appropriate law enforcement officials, and I herewith releaseand hold harmless the hospital and its agents from any and all liability and claims ofinjury whatsoever which may in any manner result from the authorized release of suchinformation.
SIGNED: ~
i)'I\~\~'f£
WITNESS:~ ~_' DATE:
1~.\5'Db
ADDRESS: PARENT OR GUARDIAN (IF APPLICABLE): --:..ADDRESS:
RE1 MS STEP1.1 2196
WHiTE - HCSPiTAUPHYSICIAN RECORDSYELLOW - RETURN TO KIT BOXPINK - POLICE DEPARTMENT
 
 MERCY HEALTH CENTER 
of Manhattan
IMAGING DEPARTMEN
1823 COLLEGE AVE. MANHATTAN. KS 66505
(785) 776-2888NAME:DOMBROWOSKI,CLAUDINE
DOB:
04/10/1965
AGE:
35 SEX:
 ACCT:
VOOOl13348
LOC:
COL.ER
EXAM DATE:
12/15/2000
STATUS:
DEP
L~'"'
REF PHYS:
Harper,Doug
 ATTN PHYS:
Harper,Doug
 MED REC#:
MOOOI05071EXAMS: 000068727 ORBITS, MIN 4 VWS#7936
ORBITS:
HISTORY: Hit in the face.FINDINGS: Waters', lateral left orbital oblique and Caldwell viewsshow no evidence of fracture. The orbital rim and orbital floor areintact. There is no abnormal soft tissue swelling.The paranasal sinuses are clear.
IMPRESSION:
No
orbital
or
facial fractures.
**
REPORT SIGNATURE ON FILE 12/15/2000
**
REPORTED BY: FRANK C. LYONS, M.D.SIGNED BY: LYONS MD,FRANKCC: Doug HarperTECHNOLOGIST: 0791 RAD.ROBRTRANSCRIBED DATE/TIME: 12/15/2000 (1533)TRANSCRIPTIONIST: RAD.BUBAKPRINTED DATE/TIME: 12/15/2000 (1701)PAGE 1MEDICAL RECORDS COpy
 
STEP 2 VICTIM'S MEDICAL HISTORY AND ASSAULT INFORMATION
(please Print)
1. Victim's Name:
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2. Date of Birth:
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3. Race:
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4.
0
Male ~) Female5. Marital Status: SCM
0
SEP ~ DIV
0
WID6. Date and time of alleged assault: ~
Ilf / ~.).OOD
_'_I :
00
AM@7. Date and time of hospital examination:
i~ /~
1-82.f}QO 
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~PM8. Examining physician:
be
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nee
9. Nurse:
~oct 
y
LVood i2..{\)
10. Between the assault and now, has the victim:Douched
I : : J
Bathed/Showered
o
Urinated
o
Defecated
o
Vomited
o
Drunk
o
Brushed Teeth~ Used Mouthwash . .
d
Shoe::
~ Changed Clothes
500
15
Attempted Successful Ejaculation
11. Was there penetration of:12. Oral/Genital Sexual Contact:13. Did assailant use:Vagina
0
Anus
0
Mouth,
0
.~~
o
Lubricant~
o
o
~ Cunnilingus
o
Condom
YesNoNot Sure
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0
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00
~
0
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Insert foreign object(s)
YES NO
14. Was victim menstruating at time of assault?15. Any consensual coitus in the last 72 hours?
D
If yes, Date: and Time: If yes, was condom used?
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16. Is victim pregnant?If yes, duration of pregnancy? 17. Any injuries to victim resulting in bleeding?
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If yes, descnbe:
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bra(,)
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18. Number of assailants? _~_~ 19. Race of assailant(s) If known:
nC L + "V ~
Q01er"CGfILlCho.n/Cauc,
20. Assailant(s) relationship to victim:Stranger
g
Acquaintance
..
Relative (Specify): ~~ Not Sure
~ No
~ NoDYesDYes21. Any injuries to assailant(s) resulting in bleeding?If yes, describe: 22. Was any medication taken by victim prior to or after assault?
...
~
..
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