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Discipline

: Emergency

Sub Discipline

: Emergency

Document Title

: OSCC Domestic Violence Clerking Note

OSCC TEAM

OSCC Administrator

PERSONAL DETAILS

Telephone

Please Update Method

Religion

Occupation

Monthly Income

Education

Marital History

Number Of Years Married

Number Of Children

Male

Female

Ages Of Children

Eldest

Youngest

INFORMATION OF ABUSER

Relationship To Victim

Age

Month(s)

Number Of Years Known To Victim

Ethnic Group

Education

Religion

Occupation

History Of Drug Abuse

YesNo

History Of Alcohol Abuse

YesNo

Any History Of Criminal Record

YesNo

HISTORY

Present Incident

Date

Time

Location

Form Of Battery

Beating/assault

Weapons

Knife

Hands

Legs

Gun

Blunt Object

Other,specify

Sexual abuse

Burns, specify

Threats on life, specify

Emotional abuse

First Time Occurred?

YesNo

Police Report Made?

YesNo

Report No

History Of Incident

History Of Past Incident

Past Medical/ Surgical/ Gynae History

PHYSICAL EXAMINATION

General Condition

GoodSatisfactoryPoor

Behaviour

CalmNervousOthers, specify

Vital Signs

Physical Examination Findings

MANAGEMENT

Plan

Orders

Referral

Outgoing Referrals

Ngo

Yes, specifyNo

Police

YesNo

Remarks

Initial Medical Report Given To Police By Attending Doctors

YesNo

Police Officer's Name

SIGNATURES

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