Strangulation Form Victim's Email Officer Email(enter your email address to receive a copy of the submitted form) CASE # SUBMITTED BY VICTIM NAME(Last, First, Middle) DATE OF BIRTH Month Day Year SEX M F SUSPECT NAME(Last, First, Middle) DATE OF BIRTH Month Day Year SEX M F STRANGULATION EVENT QUESTIONSWhat did suspect use to strangle you? Left Hand Right Hand Two Hands Forearm Knee/Foot Other Object(s) Other Object(s)Describe Describe manner/method in detail in narrative. Estimate How Long Strangulation Lasted:Minute(s) Second(s) Multiple Times: Yes No # Of Times: Estimate the Amount of Force Suspect Used:(1 = Weak, 10 = Very Strong) 1 2 3 4 5 6 7 8 9 10 Describe Suspect’s Emotional Demeanor While Strangling You: Describe the Suspect’s Face/Expression During Strangulation: What did Suspect say While Strangling You? What else did Suspect do While Strangling You? Were you able to Speak during the Strangulation? Yes No If Yes, What Did You Say? Did you do anything to attempt to physically stop the strangulation? Yes No Describe What made the suspect stop? What did you think during the strangulation? Has suspect strangled you on other occasions? Yes No If yes, # of occasions: When: SYMPTOMS EXPERIENCED BY VICTIMVision 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 Breathe 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: Describe OFFICER OBSERVED INJURIESFACE Skin Red/Flushed Red Spots (e.g. Petechiae) Scratches or Abrasions Swelling Bruising Other: Face – OtherDescribe EYES Red Eye Red Spots in Eye Red Spots on Eyelid Blood in Eyeball Eyelid(s) Drooping Other: Red Eye Left Right Red Spots in Eye Left Right Red Spots on Eyelid Left Right Eyes – OtherDescribe NOSE Skin Red/Flushed Red Spots (e.g. Petechiae) Scratches or Abrasions Swelling Bleeding Other: Nose – OtherDescribe MOUTH Swollen Lips Swollen Tongue Bruise(s) Scratches or Abrasions Red Spots in Palate or Gums, Etc. Other: Mouth – OtherDescribe EARS Redness Red spots (i.e. Petechiae) Bleeding Bruising or Discoloration Swelling Red Spots Behind Ear(s) Bruising Behind Ear(s) Other: Ears – OtherDescribe UNDER CHIN Redness Scratches or Abrasions Lacerations Bruises Linear Marks (e.g. Fingernail Marks) Other: Under Chin – OtherDescribe NECK Redness Scratches or Abrasions Bruises Linear Marks (e.g. Fingernail Marks) Ligature Marks Red Spots (e.g. Petechiae) Swelling Other: Neck – OtherDescribe SHOULDERS Redness Scratches or Abrasions Lacerations Bruises Other: Shoulders – OtherDescribe HANDS, FINGERS, ARMS Redness Bruising Swelling Scratches or Abrasions Broken Fingernails Other: Hands, Fingers, Arms – OtherDescribe Head Lumps/Bumps Lacerations Scratches or Abrasions Hair missing Red Spots on Scalp (e.g. Petechiae) Other: Head – OtherDescribe CHEST Redness Scratches or Abrasions Lacerations Bruises Linear Marks (e.g. Fingernail Marks) Other: Chest – OtherDesscribe BODY DIAGRAMSDraw all marks observedMark Injuries Choose X Choose O Reset Selections FileMax. file size: 80 MB.Mark Injuries Choose X Choose O Reset Selections FileMax. file size: 80 MB.Mark Injuries Choose X Choose O Reset Selections FileMax. file size: 80 MB.Mark Injuries Choose X Choose O Reset Selections FileMax. file size: 80 MB.Mark Injuries Choose X Choose O Reset Selections FileMax. file size: 80 MB.Mark Injuries Choose X Choose O Reset Selections FileMax. file size: 80 MB.