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Practical advice for writing medical certificates in the event of sexual violence
Medical certificate for an adult
I, the undersigned, ................................................... (fam ily nam e, first nam e), doctor of medicine,
certify that I have examined on this the ............................ (hour, d ay , m onth, y ear), at his/her
request, Mr, Mrs, Miss ...................................................... (fam ily nam e, first nam e),born on the
........................................... (d ay , m onth , y ear), living at .................................................
........................................................................................................................................ (precise ad d ress).
(S)he declares that (s)he has been the victim of sexual violence on ..................................... (hour, d ay ,
m onth, y ear) at ................................. (place), by .............................. (aggressor known or unknown).
During the interview, (s)he stated:
“ .................................................................................................................................................................. ”
Mr, Mrs, Miss .................................................... presents the following clinical signs:
– On general examination: ......................................................................................................................
(d escribe the behaviour: prostrated , ex cited , calm , frightened , m ute, tearful, etc.)
– On somatic examination: .....................................................................................................................
(d escribe precisely all lesions observed on the entire bod y : signs of abrasion, cuts, scratches,
bites, strangulation, swelling, burns etc. Ind icate th e site, th e ex tent, th e num ber, th e
character (old or recent), the severity etc.)
– On genital examination: .......................................................................................................................
(is the hy m en intact or not (if not, d id it occur recently or in the past), traum atic lesions etc.)
– On anal examination: ............................................................................................................................
(d etectable traum atic lesions etc.)
– Examinations completed (particularly sam ples taken): ..................................................................
– Evaluate the risk of pregnancy: ..........................................................................................................
In conclusion, Mr, Mrs, Miss ................................................. shows (or does not show) signs of
recent violence and an emotional response (in)compatible with the violence of which (s)he
reports to have been victim.
(R em em ber: th e absence of lesions d oes not allow a conclusion that there was no sex ual
violence).
Total Temporary Incapacity (TTI) should be granted for .......... days without consideration of
possible complications.
Sequelae may persist leaving a Partial Permanent Incapacity (PPI) to be assessed by an
expert at a future date.
This document is established with the consent of the patient and may be used for legal
purpose.
Signature of physician
323
Medical certificate for an adult
I, the undersigned, ................................................... (fam ily nam e, first nam e), doctor of medicine,
certify that I have examined on this the ............................ (hour, d ay , m onth, y ear), at his/her
request, Mr, Mrs, Miss ...................................................... (fam ily nam e, first nam e),born on the
........................................... (d ay , m onth , y ear), living at .................................................
........................................................................................................................................ (precise ad d ress).
(S)he declares that (s)he has been the victim of sexual violence on ..................................... (hour, d ay ,
m onth, y ear) at ................................. (place), by .............................. (aggressor known or unknown).
During the interview, (s)he stated:
“ .................................................................................................................................................................. ”
Mr, Mrs, Miss .................................................... presents the following clinical signs:
– On general examination: ......................................................................................................................
(d escribe the behaviour: prostrated , ex cited , calm , frightened , m ute, tearful, etc.)
– On somatic examination: .....................................................................................................................
(d escribe precisely all lesions observed on the entire bod y : signs of abrasion, cuts, scratches,
bites, strangulation, swelling, burns etc. Ind icate th e site, th e ex tent, th e num ber, th e
character (old or recent), the severity etc.)
– On genital examination: .......................................................................................................................
(is the hy m en intact or not (if not, d id it occur recently or in the past), traum atic lesions etc.)
– On anal examination: ............................................................................................................................
(d etectable traum atic lesions etc.)
– Examinations completed (particularly sam ples taken): ..................................................................
– Evaluate the risk of pregnancy: ..........................................................................................................
In conclusion, Mr, Mrs, Miss ................................................. shows (or does not show) signs of
recent violence and an emotional response (in)compatible with the violence of which (s)he
reports to have been victim.
(R em em ber: th e absence of lesions d oes not allow a conclusion that there was no sex ual
violence).
Total Temporary Incapacity (TTI) should be granted for .......... days without consideration of
possible complications.
Sequelae may persist leaving a Partial Permanent Incapacity (PPI) to be assessed by an
expert at a future date.
This document is established with the consent of the patient and may be used for legal
purpose.
Signature of physician
323
