DEPARTMENT OF FORENSIC MEDICINE

AMALTAS INSTITUTE OF MEDICAL SCIENCE, DEWAS

No. …………/AIMS/FM/MLC/Case No. – 06/23 Dewas, Dated 18 /10 /2023

To,
The Superintendent of Police / The Station Officer
Distt. Dewas / P.S. – Kotwali,
Dewas (M.P.)

Subject :- Examination of ………………………………… S/o or D/o……………….……………. in

connection with marg No. ………………... of P.S. Kotwali, Dewas (M.P.).
Reference :- Your Letter No. …………………………………. Dated 17/10/2023.

Name of a Person -
Age/Sex -
Address –
Brought by –
Date & Time of Examination –
Place of Examination –

Consent –
Identification Marks – Preferably on exposed parts of body.
1.
2.
General Examination –
General Condition –
Height –
Built –

Gait –
Speech –
Consciousness –

Orientation to time/place/person –
Judgement power –
Reaction time –
Co-ordination –
Pupils reaction to light –
Smell –
Movement of Eyes –
Clothings –
 No. …………/AIMS/FM/MLC/Case No. – 06/23 Dewas, Dated 18 /10 /2023

Preservation –
1. Blood -5ml blood taken in sterilized container (dried ) with preservation 3%
NaF & EDTA measured amount (blood collected from vein –washed cleaned
with warm water then dried )
2. Urine -10ml preserved in sterilized glass container with phenylmercuric
nitrate / thymol crystals
3. If vomitus/ gastric wash preserved in glass container with preservative
sodium fluoride NaF 3% articles preserved above , packed ,sealed ,labeled
separately along with sample of seal handed over to P.C. concerned with
the advice that they should be seat to FSL for chemical analysis.
Opinion :- On basis of chemical examination I am of the opinion ( Any one of
following )
(1) Person under examination has not consumed alcohol.
(2) Person under examination has consumed alcohol but is not under the
influence of alcohol.
(3) Person under examination is under the influence of alcohol.

Enclosed : As above.

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