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Date posted: December 31, 2011

 Certificate of death

Name of the deceased…………………………………Sex…………………………

Occupation…………………………………     Religion……………………………

Date of death…………………………………………………………… …………..

Age in years…………………………………………………………………………

If under one year……………………….months……………………days…………

If under 24 hours…………………………hours…………………………minutes

Cause of death…………………………………………………….

Disease or condition (a)……………………………………………………………

Directly leading to death (due to or as a consequence of)

(This does not mean the mode of dying, eg. Heart failure, asthma, etc, It means disease, injury or complications)

Antecedent causes (b)………………………………………………………………

Morbid condition, if any giving rise to (due to or consequence of) above cause stating the underlying condition

Other significant conditions (c) ……………………………………………………

contributory to death, but not related to the disease or condition causing it.

If the deceased was a female, was the death associated with pregnancy?…………………………………delivery?……………………………….……

Signature

Designation

Date:                                                                  Reg. No.

Death report

Ward………………………………….        No………………………………..

Municipality………………………….                  Taluk……………………………..

Panchayat…………………………….                  District……………………………

Corporation…………………………………

Full name of the deceased……………………………………………………….

Sex: Male / Female

Age at death………………………………. years

………………………………. months

……………………………….day

Nationality and caste…………………………………………………………….

Occupation of the deceased……………………………………………………..

Marital status……………………………………………………………………

Normal residence………………………………………………………………..

Place of death……………………………… Door No ………………………….

Street No…………………………

No. of ward………………………

Cause of death (if death certificate is issued)………………………………………

…………………………………………………………………………………….

Date of death……………………………….

Name of father / husband…………………………………………………………

Name of burial or burning ground ………………………………………………..

Informants                                                  Name……………………………….

Relationship…………………………

Designation and address……………

Name of medical attendant…………………………………………………………

Date                                                                              Signature

Death intimation

Hospital……………………….

Time………………………….

Date…………………………..

No…………………………….

From

Dr…………………………………………………………………………………….

………………………………………………………………………………Hospital

To

The Sub Inspector,

………………………………………………..police station

Sir,

This is to inform you that Sri/Smt………………………………………………… aged…………………………..years admitted here on ……………………….with history of …………………………………………………………and referred from

………………………………………….expired on ……………………………….. at.…………………………………..hour…………………………………………

Body is kept in the mortuary, please do the needful.

Yours faithfully,

Signature………………………

Name………………………….

Accident Register cum Wound Certificate

1.      Serial No.

2.      Date and hour of examination

3.      Name

4.      Age

5.      Sex

6.      Address

7.      Marks of identification

1…………………………………………………………..

2…………………………………………………………..

8.      By whom brought and requisition brought by…………………………..

9.      History and alleged cause of injury

10.                         Details of injuries/clinical features

11.                         No. of additional sheets, if any

12.                         Is dying declaration required?

13.                         If yes, whether police/magistrate is informed

14.                         Investigation results, if any

15.                         Date of admission as inpatient and IP No.

16.                         Date of discharge

17.                         Condition on discharge

18.                         Opinion as to the cause of injury

 

Name of the institution                                    Signature of M.O

Station                                                             Name of M.O

Date                                                                 Designation

Issued to …………………. of police as per his requisition No………………..

Dated…………………….                      Signature of issuing Medical officer

 

Letter of intimation to the police

From:

Name of the medical officer………………………………….

Designation……………………………………………………

Name of the institution……………………………………….

To:

The S.I of Police………………………………………………

 

Sir,

I write to inform you that a patient by name………………………….

aged about ……………………. S/o………………….. Inhabitant of…………..

has been brought to the causality/out-patient department at …………. a.m./p.m. on ………………………. is alleged to have been ………………… at a.m./p.m in ………………….. at (place) ………………………………………………….

He/she is being treated as out-patient/in-patient in Ward  No…………

Please do the needful.

 

Yours faithfully

Station                                                             Signature of M.O

Date

 

Scheme of examination of a victim of rape

Ref. No……………………..   Name of Institution…………………………

Name of the subject………………………………………………………………

Age (as stated by the individual)………………………… Date…………………

Referred by………………………………..

Brought by………………………………..

Informed consent given by…………………………….

(Signature and name)………………………………….

Female witness present during examination

Signature……………………………………

Name and address…………………………..

Date and time of examination……………………………………………………

Marks of identification:

1………………………………………………………………………………….

2………………………………………………………………………………….

History of the case (as stated by the subject)

Examination findings

Height………………………… cm. Weight ………………………. kg.

Condition of clothes

1.     Indicating struggle

2.     Presence of stains

3.     Any other findings.

Gait – pain during walking if any

Injuries

1.     General………………………………….

2.     Genitlia………………………………….

 

Condition of pubic hair

matted / not matted

Condition of hymen

Intact/         Elastic

Torn – tear – recent/old

Carenculae hymenalis

Condition of vagina

Admits one finger/         Admits two fingers

Rugae distinct/not distinct

Vaginal swab/smear

Sperms positive/negative        Motile/not motile

Signs of veneral disease…………………………………………………………

Nature of specimen sent for chemical analysis………………………………….

Letter No. and date of sending he specimens……………………………………

Result of chemical examination…………………………………………………

Any additional findings…………………………………………………………
Opinion

     Based on the above findings I certify that:

1.     There is no evidence/evidence of general bodily injuries

2.     There is no evidence/evidence of genital injuries/penetration

3.     There is no evidence/evidence of recent sexual act (if sperm/semen are detected in the vagina)

Signature……………………..

Name…………………………

Designation…………………..

Forwarded to ………………………………

(vide his letter No…………. dt…………………..)

 

Scheme of examination of an accused in a case of rape

Proforma

1.     Ref………………………….. requisition No…………………..date…………

2.     Accompanied by PC No……………………………

3.     Name…………………………… Age………………….. Address……………

4.     Consent (not necessary if sec 53 Cr.PC is applicable)

5.     Date, time and place of examination…………………………………………..

6.     Marks of identification

a……………………………………………………………………………….

b……………………………………………………………………………….

7.     History (as given by the police)……………………………………………….

8.     History obtained from the person regarding veneral diseases, time of taking last bath or engaging in intercourse etc.

9.     Physical examination

Height……………………..

Weight…………………….

Build………………………

Secondary sexual characters (refer potency certificate) clothes (those which he was wearing at the time of the alleged act are collected, dried and preserved for despatch to th Chemical examiner.

10.   Injuries (general)

11.   Local examination

a.     Pubic region – matting of hairs, presence of stains, foreign hairs, injuries

b.     Penis – length, circumference in the flaccid state, deformities, injuries, smegma, sensations and turgescence of glans

c.      Scrotum and testes

12.   Systemic examination (if potency is also tested)

13.   Collection of trace evidence

1.     Blood for grouping

2.     Scalp hair and pubic hairs

3.     Loose hairs on the body

4.     A swab from the glans penis or glans washings


Opinion

1.     There is no evidence/evidence of genral bodily injuries

2.     There is no evidence/evidence of genital injuries

3.     There is no evidence/evidence of recent vaginal intercourse (if vaginal epithelial cells are detected)

4.     There is no findings to suggest that the person is impotent.

 

POTENCY CERTIFICATE

Ref. No. ML…………………………………                      Dated…………….

Requisition received from the S.I of police………………………. vide his letter

No……………….dated through PC/HC No………………. for examination of potency of ……………………. aged……………………year involved in crime No……………………… of ……………………. Police station.

1.     Name and address of the subject………………………………………………

2.     Age…………………….. years (as stated by the subject)

3.     Occupation……………………………………

4.     Accompanied by………………………………

5.     Date, time and place of examination………………………….

6.     Consent…………………………………..

7.     Marks of identification:

1………………………………………………………………………………

2………………………………………………………………………………

8.     Clinical history

Diabetes/drug addiction/trauma

Exposure to venereal disease/others if any

9.     History of sexual development

Masturbation/night emission/homosexual practice/sexual intercourse

10.            Physical examination

A.   General

1.     Height………………….. cm

2.     Weight…………………..kg

3.     Build…………………….good/moderate/poor

4.     Adam’s apple

5.     Hair – pubic/axillary/facial/chest

B.   Local

1.     Penis – present/absent

Length……………………….cm (flaccid state)

Circumference……………….cm (flaccid state)

Disease (if any)

Injury (if any)

Sensation over glans penis……………….

Prepuce – retractable/non-retractable………………

2.     Scrotum

Pendulous/non-pendulous

Right testis – present/absent

Left testis – present/absent

Development of testis – small/medium/adult size

Sensation

Disease/deformity/injury if any

Epidydimis/cord

C.   Systemic examination

CVS/GIS/CNS/RS

11.            Special examination (if relevant)

12. Opinion

1.     There is nothing to suggest that the above person is incapable of performing the sexual act.

OR

2.     The above subject is incapable of performing the sexual act because of the following impediment(s).

 

Signature:

Name:

Desination:

Forwarded to: (Court)

Copy to: (Police)

Examination of a female for signs of impotence

Proforma

Requisition from………………………No……………………dated………………

accompanied by……………………………

1.     Name……………………………………. 2. Age……………………………

2.     Address…………………………………..4. Consent……………………….

5. Date, time and place of examination………………………………………….

6. Marks of identification      1…………………………………………………

2………………………………………………….

7. General examination      a. Height………………………….

b. Weight…………………………

c. Secondary sexual characters

1. Breasts   2. Axillary hair  3. Pubic hair

4. Menstrual history

Local examination     1. Vulva

2. Labia

3. Hymen

a. Description of orifice, injuries, recent and/or old
or any abnormality

b. Admits one/two fingers, with/without difficulty

c. Spasm of thigh muscles or levator muscles on
digital examination.

Hymen – present/absent

4. Vagina

a. Size of the vault (narrow/lax)

b. Rugae present or not

c. Any congenital abnormalities

Opinion

1.     There is no findings to suggest that the subject is incapable of partaking in sexual act/ The subject is capable of partaking in the sexual act (a vera copula)

OR

2.     The subject is not capable of partaking in sexual act due to………………… ……………(reason)

OR

3.     Sexual intercourse could have been taken place/ has not taken place

 

Form for age determination

Name…………………………………………………………………………………

Address………………………………………………………………………………

Requisition No………………………… Date……………….. From………………

(Escorted by………………………..P.C. No………………………..)

History………………………………

Age……………………. as stated by the individual

Consent from the subject/parent (This is not required if sec. 53 of Cr.P.C is applicable)

Date and time of examination………………………………………………………

Identification marks:

1…………………………………………………………………………………….

2…………………………………………………………………………………….

 

PHYSICAL EXAMINATION

Height……………………………….cms.

Weight………………………………cms.

General build…………………………….

Voice……………………………………. (deep or soft)

Adam’s apple……………………………. (prominent or not)

Hair – pubic……………………………… (absent/downy/sparse/black/rich)

Axillary…………………………………(do)

Moustache………………………………(do)

Breasts…………………………………..(not develop/developing/well developed)

External genitalia………………………. (in males look for the development of penis and pendulousness of scrotum and in females the prominence of labia and mons pubis)

History of menarche/ejaculation…………………………………

Other features if any……………………………………………..

 

DENTAL EXAMINATION

Total number of teeth

Temporary……………………. (number)

Permanent……………………. (number)

 

RADIOLOGICAL EXAMINATION

(X-ray photographs were taken on………………………..)

Regions                                                       Findings

1.

2.

3.

4.

 

Letter to the Radiologist

No……………..                                                             Date…………………….

To

The Radiologist

………………………………… Hospital

…………………………………

Sir,

Sub:- Age determination of ………………………………

Ref:- Requisition from………………………dated……………………..

I request that radiographs of the subject may be taken as indicated below

No.                                                    Review                                    View

1.

2.

3.

4.

The subject bears the following identification marks:

1…………………………………………………………………………………..

2…………………………………………………………………………………..

He / She is escorted by…………………………………..

I request you to kindly send the X-ray plates at the earliest.

Yours faithfully,

Name of hospital                                                  Signature

Place                                                                     Name & Designation

Age Certificate

No……………..                                                             Date…………………

I, Dr………………………………………………………… certify as hereunder

A male/female by name………………………was sent to me by………….with his requisition No………………dated…………………………… for determination of

age…………………..

The subject was accompanied by………………………… He was examined by me at………………. on……………..and the following findings were noted:

Identification marks:

1.

2.

A. PHYSICAL FINDINGS………………………………………………………………………..

B. DENTAL FINDINGS…………………………………………………………………………..

C. RADIOLOGICAL FINDINGS (X-rays taken on……………………………………..)

Based on the physical, dental and radiological findings I am of opinion that the person is aged above…………..years and below……………..years.

 

Name of hospital                                                  Signature:

Place:                                                                    Name & Designation

Forwarded to:

 

Proforma

Scheme of examination for evidence of drunkenness

Requisition from the Sub Inspector of ……………………………… police station with his letter dated………………………………………… for the examination of ………………….brought by P.C. No……………….. for evidence of drunkenness.

1.     Date and time of examination………………………………………………..

2.     Name, age and address………………………………………………………

3.     Identification marks:

a……………………………………………………………………………..

b……………………………………………………………………………..

4.     History: (engage in conversation and enquire)

a.     Whether he did take alcohol or not, how he feels?

b.     What food and drink he took last and when?

c.      Does he have any fits, illness or other disability?

d.     If a diabetic, when was insulin taken last and how much?

5.     General appearance and demeanour: (Observe during conversation)

a.     State of clothing – decent, disarrayed, soiled……………………………..

b.     Deposition – calm, talkative, abusive, obscene……………………………

c.      Speech – normal, thick and slurred, overprecise

d.     Gait – steady or staggering

6.     Memory: Ask suitable questions about his movements during the preceeding few hours, details of accident if any, the time of arrest etc.

7.     Mouth: smell of alcohol in the breath / dribbling of saliva / lips dry or not / tongue dry, moist, furred, bitten, coated etc.

8.     Eyes: Test visual acquity across 20 ft.

Lateral nystagmus; conjunctiva suffused or not; state of pupils and its reaction to light

9.     Ears: Impairment of hearing if any

10.  Pulse and blood pressure……………………………………………………..

11.  Temperature……………………….. skin dry or moist

12.  Respiration…………………………. nature and rate, hiccup

13.  Reflexes……………………………. superficial and deep.

14.   Muscular co-ordination………………………….. perform several tests.

a.     Walking along a straight line

b.     Picking up an object from the floor

c.      Finger-nose test

d.     Romberg’s sign

e.      Handwriting

f.       Copying simple geometric figures

15. C.N.S. and other systems to exclude other conditions.

16. Collect samples of blood or urine for chemical examination.

 

Certificate of Drunkenness

Signs of alcoholism found on the person of ……………………..aged…………….. years, an inhabitant of ………………………………… sent by the Sub Inspector of

Police………………….. with the letter dated…………. …….and accompanied by P.C.No………………… for examination and certification.

The person was first seen by the undersigned at…………………………………… on ……………………… and the examination was conducted at………………….. on……………………….. when the following were found:

Identification marks:

1………………………………………………………………………………………

2………………………………………………………………………………………

Physical findings: (enter all the relevant positive and negative findings).

Based on the above findings I am of opinion that the above person

a.     Has consumed alcohol and is under its influence

b.     Has consumed alcohol and is not under its influence

c.      Has not consumed alcohol

(Score out whichever is not applicable)

Signature………………………

Name………………………….

Date:…………………………                              Designation……………………

Station………………………                               Address………………………..

 

Download the pdf versionwww.similima.com/pdf/certificates- required-practitioner.pdf

Comments

2 Responses so far.

  1. Dr. ROSE DEEPTHY G says:

    Thanks a lot. This is the information I have been looking for a long time yet.

  2. Dr.abdul basheer.c says:

    Thanks a lot

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