Date/Time of Assessment:

Method/Manner of Strangulation:

One hand	Estimated length of time: seconds	minutes

Two hands	Estimated length of time: seconds	minutes

“Chokehold”	Estimated length of time: seconds	minutes

Approached from the front

Approached from behind

Multiple strangulation attempts during incident	How many?

Jewelry on patient’s neck during strangulation

Ligature used	Describe if possible:

Smothering attempt	Describe:

Other	Describe:

During the strangulation did the patient note any of the following:

Loss of consciousness/blacking out/passing out	Number of times:

Incontinence of urine	Incontinence of stool

Bleeding	Describe:

Patient’s feet lifted off the ground

Patient’s shirt was tightened around their neck

Since the strangulation, has the patient noted any of the following symptoms:

Coughing	Drooling Dyspnea Dysphagia Odynophagia Headache

Lightheadedness Neck pain Neck swelling Nose pain Nausea Vomiting

Crepitus Uncontrolled shaking Combativeness Irritability Restlessness

Otherwise altered mental status	Describe:

Voice changes	Describe:

Vision changes	Describe:

Bleeding	Describe:

Weakness/numbness of extremities	Describe:

Pressure and Pain Assessment

Pain score:	Numbered scale used	Wong Baker scale used

On a scale of 0-10, with 0 being no pressure and 10 being the worst pressure you can imagine, how strong was the grip during your strangulation (Circle one):

0	1	2	3	4	5	6	7	8	9	10

Examination (Strangulation specific – a full physical exam should be documented elsewhere)

Is the patient pregnant?	Yes	; How many weeks?	No

Oxygen Saturation

Saturation:	Time:

Saturation:	Time:

Lung sounds:	WNL	Abnormal:

Heart sounds: WNL	Abnormal:

Carotid pulse: WNL	Abnormal:

Petechiae

(Locations: Conjunctivae	Face Ears Neck Chest)

Tongue or oral cavity injury	Describe:

Neurological findings

Ptosis Facial droop Paralysis Unilateral weakness Loss of sensation

Other:

Absence of normal crepitus when manipulating cricoid cartilage

Visible injury (describe on body maps below)

Digital photography complete

Cranial Nerve Assessment

Nerve	Assessment	Notes
CN I Olfactory	Identifies a familiar scent with eyes closed (coffee)	WNL Unable to assess
CN II Optic	Read one eye at a time, visual fields tested by having patient cover one eye and identifying number of fingers in each visual field	WNL Unable to assess
CN III Oculomotor	Check pupillary response with light, check accommodation by moving your finger towards the patient’s nose, check for EOMs	WNL Unable to assess
CN IV Trochlear	Have patient look down and in	WNL WNL Unable to assess
CN V Trigeminal	Ask patient to open mouth while you attempt to close it, have them attempt to move jaw laterally. Have patient close their eyes, touch their face with cotton and have patient identify where they were touched.	WNL Unable to assess
CN VI Abducens	Have patient move their eyes from side to side	WNL Unable to assess
CN VII Facial	Ask patient to smile and raise eyebrows, ask them to keep eyes and lips closed while you try to open them	WNL Unable to assess
CN VIII Acoustic/Vestibular	Test hearing with rubbing fingers or whispering	WNL Unable to assess
CN IX Glossopharyngeal	Observe patient swallow and check gag reflex	WNL Unable to assess
CN X Vagus	Assess gag and swallowing with IX, assess patient’s voice characteristics	WNL Unable to assess
CN XI Spinal Accessory	Have patient shrug shoulders with resistance, have patient move head from side to side.	WNL Unable to assess
CN XII Hypoglossal	Have patient stick out toungue and move it internally from right to left, assess articulation.	WNL Unable to assess

Describe abnormalities here:

Cranial nerve assessment normal

EYE DIAGRAMS (Document any injuries):

RIGHT CONJUNCTIVA	RIGHT INNER EYE LID	RIGHT OUTER EYELID

LEFT OUTER EYELID	LEFT INNER EYE LID	LEFT CONJUNCTIVA

Name of examiner:	Date:

Signature: ____________________________________________