Past medical history: Medical examination: .............................................................................................. Pulse rate:........................................ .............................................................................................. B.P.: ............................................... .............................................................................................. Temp.: ........................................ °C Drugs/Medication...................................................................... Ht: .............................................cm .............................................................................................. Wt:............................................ kg .............................................................................................. Morphometry ................................... ..................................................... General medical examination: ..................................................... .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. .............................................................................................. Record of findings: X-rays Photography Video Other....................................................................................... .............................................................................................. Examiner: Name................................................................. Signature .................................................................... Professional address .............................................. Time …………… hrs Date …… / …… / ……. ......................................................................... Tel ................................... Fax .................................... Notes on wound description: 1. In describing a wound consider the following features: Site Colour Age Size Contours Borders Shape Course Classification Surrounds Contents Depth 2. Ensure descriptions are consistent with the following definitions: Abrasion – A superficial scraping injury of the body surface with or without bleeding Bruise – Leakage of blood from blood vessels discolouring the tissues of the body Incision – A cutting-type injury that severs tissues in a clean and generally regular fashion 3. All descriptions of wounds and injuries should be made by reference to the subject in the standard anatomical positions. 4. The use of terms such as Superior, Inferior, Anterior and Posterior should refer to the subject in standard anatomical position. 5. The measured position of wounds on the body should be located by reference to fixed bony landmarks. 6. The accurate classification of a wound type has major significance for determining injury causation. 7. An accurate Forensic Medical examination should assist in the reconstruction of the events in which the injury occurred. Laceration – A tear or split in tissues 83