STRANGULATION SUPPLEMENTAL DR#:(Required) Name(Required) Last First Middle Date of Birth Month Day Year Gender M F STRANGULATION EVENT QUESTIONS1. WHAT DID SUSPECT USE TO STRANGLE YOU?DESCRIBE MANNER/METHOD IN DETAIL IN NARRATIVE. Left Hand Right Hand Two Hands Forearm Knee/Foot Other Other: Describe 2. ESTIMATE HOW LONG STRANGULATION LASTED:Minute(s) 2. ESTIMATE HOW LONG STRANGULATION LASTED:Second(s) OCCURRED MULTIPLE TIMES? Yes No IF YES, HOW MANY? 3. ESTIMATE THE AMOUNT OF FORCE SUSPECT USED TO STRANGLE:(1 = WEAK; 10 = VERY STRONG) 1 2 3 4 5 6 7 8 9 10 4. DESCRIBE SUSPECT'S EMOTIONAL DEMEANOR WHILE STRANGLING YOU: 5. DESCRIBE SUSPECT'S FACE/EXPRESSION DURING STRANGULATION: 6. WHAT DID SUSPECT SAY WHILE STRANGLING YOU? 7. WHAT ELSE DID SUSPECT DO WHILE STRANGLING YOU? 8. WERE YOU ABLE TO SPEAK DURING THE STRANGULATION? Yes No IF YES, WHAT DID YOU SAY? 9. DID YOU DO ANYTHING TO ATTEMPT TO PHYSICALLY STOP THE STRANGULATION? Yes No DESCRIBE: 10. WHAT MADE THE SUSPECT STOP? 11. WHAT DID YOU THINK DURING THE STRANGULATION? 12. HAS SUSPECT STRANGLED YOU ON OTHER OCCASIONS? Yes No IF YES, INDICATE NUMBER OF OCCASIONS: WHEN/WHERE 13. IF YOU ARE HAVING TROUBLE REMEMBERING, WHAT DO YOU REMEMBER ABOUT WHAT HAPPENED?DESCRIBE IN DETAIL IN NARRATIVE.SYMPTOMS EXPERIENCED BY VICTIM(Check all that apply)Vision Changes: Tunnel DURING AFTER Vision Changes: Spots DURING AFTER Hearing Loss/Changes DURING AFTER Loss of Consciousness DURING AFTER Unable to Breathe DURING AFTER Difficulty Breathing DURING AFTER Rapid Breathing DURING AFTER Pain While Breathing DURING AFTER Shallow Breathing DURING AFTER Coughing DURING AFTER Coughing Blood DURING AFTER Nausea DURING AFTER Vomit/Dry Heaving DURING AFTER Dizziness DURING AFTER Headache DURING AFTER Feel Faint DURING AFTER Disorientation DURING AFTER Memory Loss DURING AFTER Painful to Speak DURING AFTER Raspy Voice DURING AFTER Hoarse Voice DURING AFTER Loss of Voice DURING AFTER Whisper Voice DURING AFTER Neck Pain/Tender DURING AFTER Trouble Swallowing DURING AFTER Pain Swallowing DURING AFTER Sore Throat DURING AFTER Urinate DURING AFTER Defecate DURING AFTER Other: DURING AFTER Other Symptom: Describe OFFICER OBSERVED INJURIES(Check all that apply)FACE Skin Red/Flushed Red Spots (e.g. Petechiae) Scratches or Abrasions Swelling Bruising EYES Red Eye Red Spots in Eye Red Spots on Eyelid Blood in Eyeball Eyelid(s) drooping Red Eye L R Red Spots in Eye L R Red Spots on Eyelid L R NOSE Skin Red/Flushed Red Spots (e.g. Petechiae) Scratches or Abrasions Swelling Bruising MOUTH Swollen Lips Swollen Tongue Bruise(s) Scratches or Abrasions Red Spots in Palate/Gums EARS Redness Red Spots (e.g. Petechiae) Bleeding Bruising or Discoloration Swelling Red Spots Behind Ear(s) Bruising Behind Ear(s) UNDER CHIN Redness Scratches or Abrasions Lacerations Bruise(s) Linear Marks (e.g. Fingernail Marks) Other: UNDER CHIN – OtherDescribe NECK Redness Scratches or Abrasions Bruise(s) Linear Marks (e.g. Fingernail Marks) Ligature Marks Red Spots (e.g. Petechiae) Swelling SHOULDERS Redness Scratches or Abrasions Lacerations Bruise(s) Other: SHOULDERS – OtherDescribe HANDS, FINGERS, ARMS Redness Bruising Swelling Scratches or Abrasions Broken Fingernails HEAD Lumps/Bumps Lacerations Scratches or Abrasions Hair Missing Red Spots on Scalp (e.g. Petechiae) CHEST Redness Scratches or Abrasions Lacerations Bruise(s) Linear Marks (e.g. Fingernail Marks) OTHER(Describe)REPORTING OFFICER NAME(Required) BADGE # Date MM slash DD slash YYYY Time Hours : Minutes Enter an email address to send a copy of this completed form to:(Required)