Date of Examination______________ Time of Examination________________
Alleged time of offence_______AM/PM Married/Unmarried_________
Brought by____________________________________
Consent for examination_______________________________________________
(Note : Explain to the individual that the physical examination findings will be used as evidence whether or not in his interest and he is free to refuse being examined if he chooses)
Thumb Impression/Signature
Identification Marks (1) _____________________________
(2) _____________________________
History
Specifically enquire about
a. Whether bath was taken? If yes, When ?
b. Whether motion was passed? If yes, When?
c. Clothing changed? If no, describe any damage/stains.
Physical Examination
Height___________ cms
Weight_______________ Kgs.
General Build and Appearance.
Marks of general violence on the body as bite marks, scratches etc.
General Behaviour (Mental condition & Signs of Drunkenness, if any):
Pubic region and thighs. (look for matting of hair, stains)
injuries on Genitals/Scars.
Has Vasectomy been performed? If yes, look for the Scar.
Is there any evidence of S T D?
Genitals :
Penis
Prepace
Smegma
Public Hair Length ____________ Matted or Not
Normal/Abnormal, describe the Abnormality:
Circumcised Yes/No Any Injury:
Present/Absent Any Evidence of Impotence
Microscopic examination of discharge if present:
Blood Group examination (if necessary)
OPINION:
Station :
Date :
Signature of Medical Officer
Name: Degree
Designation Reg No.
To,
SI ________________________of_________________________Police Station
Note :
a. Examination for Age Estimation to be carried out, if necessary.
b. If impotence is the plea, examination in detail for Impotence to be carried out.
Form of Report to be used when Forwarding Substances other than Viscera to
The Chemical Analyser No:
From :
To
The Chemical Analyser,
___________________ Dated:
Forwarding the articles mentioned below for examination for
____________________________ in connection with the case of
DESCRIPTION OF ARTICLES
Mode of packing and weight of parcel Copy of label and impression of seal
If standard boxes and bottles are used
a) Box No
b) Bottle No
Mode of dispatch Date and receipt in Chemical Analyser’s
Date : Office
Facts of Medico-legal importance in connection with case:
