National Guidelines on Management of Sexual Violence in Kenya

3 History Taking and Examination
History taking and examination of the survivor should be undertaken immediately in
a safe and trusting environment. For a survivor who can not be examined immediately
because of the extent of the trauma experienced, s/he should be given first aid and then
referred to a trauma counselor for stabilization.
Before starting the physical examination, take time to explain all the procedures to the
survivor and why they are necessary. Give your survivor a chance to ask any questions.
Allow the survivor to have a family member or friend present throughout the examination,
if s/he so wishes. Throughout the physical examination, inform the survivor what you
plan to do next and ask for permission. Always let the survivor know when and where
touching will occur. Show and explain instruments and collection materials. Survivors
may refuse all or parts of the physical examination and you must respect the survivor’s
decision. Allowing the survivor a degree of control over the physical examination is
important for her/his recovery.
Both medical and forensic specimens should be collected during the course of the
examination. Make sure that the survivor understands that she can stop the procedure
at any stage if it is uncomfortable for her/him and give her/him ample opportunity to
stop the examination, if necessary. Always address survivors’ questions and concerns in
a non-judgmental, emphatic manner. Use a calm tone of voice.
The findings of medical history, examination and sample collection should be carefully
and precisely documented in the PRC form (annex 6 PRC Form).
3.1 History Taking for Adults
General history:
• Tell me about your general health.
• Have you seen a nurse or a doctor lately?
• Have you been diagnosed with any illnesses?
• Have you had any operations?
• Do you suffer from any infectious diseases?
• Do you have any allergies?
• Are you currently taking any tablets or medicine?
Gynaecological history:
• When was the first day of your last menstrual period?
• Had you had any sexual intercourse prior to this incident?
• Have you had any pregnancies?
• Do you use contraception? What type?
• Do you currently have a sexual partner?
• When did you have the last consented sexual intercourse?
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