Medical certificate for a child


I, the undersigned, ............................................................................ (family name, first name), doctor of medicine,
certify that I have examined on
......................................................... (hour, day, month, year),
.............................................................................. (child’s family name, first name), 
born on the
.......................................................... (day, month, year), 
living at ................................................................................................................................................................................................... (precise address of the parents or residence of the child), 
at the request of
................................................... (father, mother, legal representative), 
who declares that the child was the victim of sexual assault on.............................................. (hour, day, month, year) 
at ........................................................................................... (place).


During the interview, the child told me: 
“ .............................................................................................................................................................................................................................................
............................................................................................................................”
(quote as faithfully as possible the words of the child without interpreting them)

During the interview, ..................................................................................... (name of the person accompanying the child) stated:
“ .............................................................................................................................................................................................................................................
............................................................................................................................” 


This child presents the following clinical signs:

– On general examination: 
................................................................................................................................................................................................................................................
............................................................................................................................
(describe the behaviour: prostrated, excited, calm, frightened, mute, tearful, etc.)

– On somatic examination:
................................................................................................................................................................................................................................................
............................................................................................................................
(describe precisely all lesions observed on the entire body: signs of abrasion, cuts, scratches, bites, strangulation, swelling, burns etc. Indicate the site, the extent, the number, the character (old or recent), the severity etc.)

– On genital examination:
................................................................................................................................................................................................................................................
............................................................................................................................
(is the hymen intact or not (if not, did it occur recently or in the past), traumatic lesions, genital infection etc.)

– On anal examination: 
................................................................................................................................................................................................................................................
............................................................................................................................
(detectable traumatic lesions etc.)

– Examinations completed (particularly samples taken):
.................................................................................................................................................................................................................................................


In conclusion (optional)
☐ This patient presents physical signs and an emotional reaction compatible with the assault of which (s)he claims to have been victim.
☐ The use of constraint and threat during the assault, or the time period between the date of the assault and the date of the medical consultation, can explain the absence of signs of physical violence on this patient.


This document is established with the consent of .................................................................. (father, mother or legal representative) and may be used for legal purpose.

Signature of physician