The information that is important in rendering a halachic ruling is summarized in the following list of questions. This form can be printed out as a written report whose completion will minimize the chance of errors in transmission. Click here, for the printable form.
Name of procedure / type of examination: ___________
| 1. | According to the patient, was she niddah prior to the examination / procedure? [ ] yes [ ] no |
| 2. | Was she experiencing bleeding prior to the examination/procedure?
[ ] active bleeding |
| 3. | Were any lesions seen on the vaginal lining that could bleed? [ ] yes [ ] no |
| 4. | If so, would one expect constant bleeding, intermittent bleeding, or bleeding on touch only?
[ ] constant bleeding |
| 5. | Were any lesions seen on the cervix that could bleed? [ ] yes [ ] no |
| 6. | If so, would one expect constant bleeding, intermittent bleeding, or bleeding on touch only?
[ ] constant bleeding |
| 7. | If there is a need to enter the uterine cavity, what was the diameter of the instrument that entered the cervical canal? __________ mm. |
| 8 | Was a tenaculum was used? [ ] yes [ ] no |
| 9. | Could the examination or procedure itself lead to any spotting or bleeding? [ ] yes [ ] no |
| 10. | If so, what is/are the likely source(s) of the bleeding? [ ] vaginal wall [ ] outside of cervix [ ] cervical canal [ ] uterus |
| 11. | For how long was this bleeding expected to last? (For example, the scraping of a Pap smear may be followed by a day or so of spotting.) ______ days |