| 1 | Sex | Girl |
| | | Boy |
| 2 | Age | 0 to 4, 5 to 9, 10 to 14 |
| 3 | Number of siblings | |
| 4 | Care situation | Both biological parents, single parent, foster care, and so on |
| 5 | Familial disease | Yes/no |
| 6 | Kind of familial disease | |
| 7 | Biol. Parents drug abuse | Yes/no |
| 8 | Biol. Parents chronic somatic illness | Yes/no |
| 9 | Biol. Parents chronic psychiatric disease | Yes/no |
| 10 | Biol. Parents other health problem | Yes/no |
| 11 | Caregiver (if not biological parent) drug abuse | Yes/no |
| 12 | Caregiver chronic somatic illness | Yes/no |
| 13 | Caregiver chronic psychiatric disease | Yes/no |
| 14 | Caregiver other health problem | Yes/no |
| 15 | Parents in conflict with each other | Yes/no |
| 16 | Parents in conflict with others | Yes/no |
| 17 | Residence | City, village, district |
| | Former disease/disability of the child: | |
| 18 | Reduced vision | Yes/no |
| 19 | Reduced hearing | Yes/no |
| 20 | Reduced mobility | Yes/no |
| 21 | Mentally disabled | Yes/no |
| 22 | Chronic somatic disease | Yes/no |
| 23 | Type of somatic disease | |
| 24 | Chronic psychiatric disease | Yes/no |
| 25 | Type of psychiatric disease | |
| 26 | Learning difficulties | Yes/no |
| 27 | Self-harm, suicidal behavior | Yes/no |
| 28 | Fractures/trauma | Yes/no |
| 29 | Allergy/intolerance | Yes/no |
| 30 | Headache/migraine | Yes/no |
| 31 | Stomachache | Yes/no |
| 32 | Eating problems | Yes/no |
| 33 | Other pain | Yes/no |
| 34 | Constipation/diarrhea | Yes/no |
| 35 | Urinary tract infection or other symptoms | Yes/no |
| 36 | Other problems | Yes/no |
| | Later diagnosed disease/problems with possible relevance | |
| 37 | Reduced vision | Yes/no |
| 38 | Reduced hearing | Yes/no |
| 39 | Reduced mobility | Yes/no |
| 40 | Mentally disabled | Yes/no |
| 41 | Chronic somatic disease | Yes/no |
| 42 | Type of somatic disease | |
| 43 | Chronic psychiatric disease | Yes/no |
| 44 | Type of psychiatric disease | |
| 45 | Learning difficulties | Yes/no |
| 46 | Self-harm, suicidal behavior | Yes/no |
| 47 | Fractures/trauma | Yes/no |
| 48 | Allergy/intolerance | Yes/no |
| 49 | Headache/migraine | Yes/no |
| 50 | Stomachache | Yes/no |
| 51 | Eating problems | Yes/no |
| 52 | Other pain | Yes/no |
| 53 | Constipation/diarrhea | Yes/no |
| 54 | Urinary tract infection or other symptoms | Yes/no |
| 55 | Other problems | Yes/no |
| 56 | Former referred to community health service for psychiatric difficulties | Yes/no |
| 57 | Type of health service | |
| 58 | Former referred to child and adolescent mental health service (CAMHS) or pediatric clinic for psychiatric difficulties | Yes/no |
| 59 | Type of health service | |
| 60 | Present medication | |
| 61 | Type of medication | |
| 62 | Who referred patient | Direct contact, police, general practitioner, school nurse, child protective service, CAMHS, and so on |
| 63 | Other referral | |
| | Registered contacts in patient record system | |
| 64 | Indirect contact (with other services) | Number |
| 65 | Direct contact with child present | Number |
| 66 | Direct contact without child present | Number |
| 67 | Phone/email contact | Number |
| | Judiciary actions | |
| 68 | Police report | Yes/no |
| 69 | Police interrogation | Yes/no |
| 70 | Trial conducted | Yes/no |
| 71 | Conviction | Yes/no |
| 72 | Acquitted | Yes/no |
| 73 | Dismissed | Yes/no |
| 74 | Other | |
| 75 | Non-judiciary actions (e.g., regulation of visitation) | Yes/no |
| 76 | Child protective actions | Yes/no |
| | Characteristics of abuse | |
| 77 | Psychological abuse | Yes/no |
| 78 | Physical abuse | Yes/no |
| 79 | Sexual abuse | Yes/no |
| | Relationship to suspected offender | |
| 80 | Biological father | Yes/no |
| 81 | Stepfather/foster father | Yes/no |
| 82 | Biological mother | Yes/no |
| 83 | Stepmother/foster mother | Yes/no |
| 84 | Sibling | Yes/no |
| 85 | Stepsibling/half-sibling | Yes/no |
| 86 | Grandfather/grandmother | Yes/no |
| 87 | Uncle/aunt/cousin | Yes/no |
| 88 | Other relative | Yes/no |
| 89 | Boyfriend/girlfriend | Yes/no |
| 90 | Friend/acquaintance | Yes/no |
| 91 | Person of authority | Yes/no |
| 92 | Stranger | Yes/no |
| 93 | Unknown | Yes/no |
| 94 | Psychological reaction at first contact | None, moderate (e.g., anxious, sadness), severe (e.g., depression, despair, disorientation), not possible to evaluate |
| | Severity of abuse | |
| 95 | Severe physical violence (e.g., fractures, internal bleeding) | Yes/no |
| 96 | Moderate physical violence (e.g., bruises, wounds) | Yes/no |
| 97 | Severe sexual abuse (oral, vaginal, anal penetration, forced masturbation) | Yes/no |
| 98 | Moderate sexual abuse (e.g., touching/fondling of intimate area, showing pornography) | Yes/no |
| 99 | Psychological abuse | Yes/no |
| 100 | Unknown severity | Yes/no |
| 101 | Threats from offender | Yes/no |
| 102 | Conclusion | Confirmed, uncertain/suspected abuse, disproved |
| 103 | Previous abuse (sexual, physical, psychological) | Yes/no |
| 104 | Time span since abuse at time of examination | <24 hours, 1 to 7 days, 1 to 4 weeks, 1 to 2 months, 3 to 6 months, >6 months, unknown |
| 105 | If repeated abuse, time since first event | <2 months, 2 to 6 months, 6 to 12 months, 1 to 2 years, 2 to 5 years, >5 years, unknown |
| | Psychological symptoms reported by patient/caregiver or other | |
| 106 | Sadness | Yes/no |
| 107 | Anxiety | Yes/no |
| 108 | Tired/exhausted/lack of initiative | Yes/no |
| 109 | Suicidal thoughts | Yes/no |
| 110 | Antisocial behavior | Yes/no |
| 111 | Abusing others | Yes/no |
| 112 | Impulsivity | Yes/no |
| 113 | Sexualized behavior | Yes/no |
| 114 | Delusions | Yes/no |
| 115 | Attention problems | Yes/no |
| 116 | Hyperactivity | Yes/no |
| 117 | Flashbacks | Yes/no |
| 118 | Nightmares | Yes/no |
| 119 | Avoidance | Yes/no |
| 120 | Memory loss | Yes/no |
| 121 | Nervous/alert | Yes/no |
| 122 | Irritability/tantrums | Yes/no |
| 123 | Dissociation | Yes/no |
| 124 | Other problems reported by patient | Yes/no |
| 125 | Other problems reported by caregiver | Yes/no |
| 126 | Other problems reported by others | Yes/no |
| 127 | If others, who | |
| | Psychiatric findings reported by doctor or psychologist: | |
| 128 | Anxious/depressed | Yes/no |
| 129 | Withdrawn/depressed | Yes/no |
| 130 | Social problems | Yes/no |
| 131 | Thought problems | Yes/no |
| 132 | Attention problems | Yes/no |
| 133 | Rule-breaking behavior | Yes/no |
| 134 | Aggressive behavior | Yes/no |
| | Somatic and psychosomatic symptoms and findings | |
| 135 | Sleeping problems | Yes/no |
| 136 | Eating problems | Yes/no |
| 137 | Headache | Yes/no |
| 138 | Muscle/skeletal pain | Yes/no |
| 139 | Gastrointestinal problems | Yes/no |
| 140 | Diffuse pain | Yes/no |
| 141 | Pelvic pain | Yes/no |
| 142 | Dysuria | Yes/no |
| 143 | Other symptoms and findings from sexual organs or anal area | Yes/no |
| 144 | Other problems reported by patient | Yes/no |
| 145 | Other problems reported by caregiver | Yes/no |
| 146 | Other problems reported by others | Yes/no |
| 147 | If others, who | |
| | Physical findings | |
| 148 | Physical findings documented in patient record | Yes/no |
| 149 | Light (superficial wounds, bruises) | Yes/no |
| 150 | Moderate (wounds, cuts) | Yes/no |
| 151 | Severe (fractures, internal bleeding) | Yes/no |
| 152 | Marks on neck/throat | Yes/no |
| 153 | Injuries in sexual area | Yes/no |
| 154 | Injuries in anal area | Yes/no |
| 155 | Sexually transmitted disease | Yes/no |
| 156 | Other | Yes/no |
| | School functioning | |
| 157 | Academic difficulties | Yes/no |
| 158 | Increased absence since time of abuse | Yes/no |
| 159 | Unchanged | Yes/no |
| 160 | Social problems | Yes/no |
| 161 | Alcohol use | Never, mild (1 to 2 times), heavy (several times) |
| 162 | Drug abuse | Never, mild (cannabis), heavy |
| | Follow-up | |
| 163 | Referred to CAMHS | Yes/no |
| 164 | Pediatrician at children’s clinic | Yes/no |
| 165 | Psychologist at children’s clinic | Yes/no |
| 166 | Child protective service | Yes/no |
| 167 | Community health service | Yes/no |
| 168 | School psychologist | Yes/no |
| 169 | Other | Yes/no |
| 170 | C-GAS | 0-100 |
| 171 | Commentary | |
