Name

Name of
of the
the patient:...........
patient:...........
Age:…………………………..
Age:…………………………..
Sex:………………………………..
Sex:………………………………..
Address:
Address: ………………………….
………………………….
Date:…………………
Date:…………………
Time:……………..
Time:……………..
Name
Name of
of the
the doctor:…………..
doctor:…………..
His
His situation:……………….
situation:……………….
 Type
Type of
of lesion:……………………….
lesion:……………………….
Number
Number of
of lesions
lesions :…………..
:…………..
Dimensions:……………
Dimensions:……………
Site
Site of
of lesion
lesion :………………
:………………
Type
Type of
of instrument
instrument used
used to
to
produce
produce lesion:………………
lesion:………………
 Other
Other lesions
lesions suspected
suspected to
to be
be
present
present :……………
:……………
The
The type
type of
of treatment
treatment received:
received:
……………………
……………………
The
The time
time necessary
necessary for
for cure:……
cure:……
Signature
Signature
 Type
Type of
of injuries:
injuries:
•• Abrasion
Abrasion
•Contusion
•Contusion
•Contused wound
•Contused wound
•Stab wound
•Stab wound
•Cut wound
•Cut wound
•Amputation
•Amputation
•Firearm wounds
•Firearm wounds (inlet
(inlet or
or exit)
exit)
:Number of lesions
One
Two
Multiple

Dimensions length χ width in

:

cm

Site of
lesion:
 Type of instrument used to
:produce lesion
Firearm weapons:
(Rifled or non rifled )

Sharp instrument Blunt instrument

With rough
surface or
pointed end
 Other lesions suspected to
:be present
According to type of injury which may be:
o Abrasion: Nothing
o Contusion, contused wound: contusion &
lacerations of underlying structures.
o Cut wound: Cutting of underlying structures.
According to site of injury:
o Head injuries accompanied by: fracture of
skull, meningeal Hg and brain injuries.
 The type of treatment
:received
Abrasions: bands- antibiotic – anti
tetanic serum vaccine.
Bruises: fomentation- antibiotic - and
X-ray.
Contused wound: stitches –bands-
antibiotic- anti tetanic serum vaccine.
Cut wound:   stitches –bands-
antibiotic- anti tetanic serum vaccine.
:Contused wound in the scalp
Stitch s–bands- antibiotic- anti
tetanic serum vaccine.
Admission to hospital and placed under
observation for 48 hours .
X-ray on the head and consultation
of neurosurgeon.
Stab wound in the chest
Admission to hospital for exploration.
X-ray on the chest and consultation
of cardio thoracic surgeon
The time necessary for
: cure
Less than 20 days if complications not
occur.
Less than 20 days with permanent
infirmity
More than 20 days
Admission to hospital and the final report
at discharge.
Admission to hospital and the final report
at discharge and repeated consultation of
forensic pathologist.