Report a Significant Medical Finding

Thank you for helping the Institute on Strangulation Prevention's Forensic Medical Committee collect cases of carotid dissections and significant neck injuries. Using the form below, please report significant medical findings.

This form can be completed multiple times if you have more than one case.

Question Title

* 1. Estimated Date of Injury

Date / Time

Date

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* 2. Point of Contact

Name *

City/Town *

State/Province *

Country

Email Address *

Phone Number

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* 3. Agency

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* 4. Age of victim/patient

Minor

Adult

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* 5. Sex of victim/patient

Female

Male

Other

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* 6. Method of Strangulation (Check all that apply)

Manual

Ligature

Suffocation

Other (please specify)

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* 7. Please check all injuries that apply:

Visible External Injuries

Pain

Abrasions/Contusions

Loss of Consciousness

Urination

Defecation

Carotid Artery Injury

Vertebral Artery Injury

None

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* 8. Please check all outcomes that apply:

Stroke

Traumatic Brain Injury

Concussion

Fracture of Hyoid Bone

Thyroid Storm

Death

Other (please specify)

Question Title

* 9. Medical Evaluation

CTA

MRA

Ultrasound

Unknown

Other (please specify)

Question Title

* 10. Is the victim or family willing to share records, including radiographic images?

Yes

Unknown

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* 1. Estimated Date of Injury

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* 2. Point of Contact

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* 3. Agency

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* 4. Age of victim/patient

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* 5. Sex of victim/patient

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* 6. Method of Strangulation (Check all that apply)

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* 7. Please check all injuries that apply:

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* 8. Please check all outcomes that apply:

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* 9. Medical Evaluation

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* 10. Is the victim or family willing to share records, including radiographic images?

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* 11. Is there anything else you would like us to know?