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I. Case information
The following guidelines are based on the Istanbul Protocol. They are not intended to be a fixed prescription, but should be applied taking into account the purpose of the evaluation and after an assessment of available resources. Evaluation of physical and psychological evidence of torture and ill‑treatment may be conducted by one or more clinicians, depending on their qualifications.
Date of exam: ....................................................... Case or report No.: .......................
Exam requested by (name/position): .....................................................................................
Subject’s ID No: .......................................................................................................
Duration of evaluation (hours/minutes): ............................................................................
Subject’s given name: ............................................................................................................
Subject’s family name: .................................................................................................................
Birth date: .................................... Birth place: ...........................................................................
Gender: Male Female Other
Reason for exam: .................................................................................................................
Clinician’s name: .................................................................................................................
Interpreter: Yes No Name..................................................................................................
Informed consent: Yes No If no informed consent, why?: ....................................................
Subject accompanied by (name/position):........................................................................
Persons present during exam (name/position):....................................................................
Subject restrained during exam: yes no If “yes”, how/why?..................................................
Clinical report transferred to (name/position/ID No.):..........................................................
Transfer date:............................................Transfer time:
Clinical evaluation/investigation conducted without restriction (for subjects in custody) yes no
Provide details of any restrictions: ...........................................................................................................................................
II. Clinician’s qualifications (for judicial testimony)
Clinical education and clinical training
Psychological/psychiatric training
Experience in documenting evidence of torture and ill‑treatment
Regional human rights expertise relevant to the investigation
Relevant publications, presentations and training courses
Curriculum vitae.
III. Statement regarding veracity of testimony (for judicial testimony)
For example: “I personally know the facts stated below, except those stated on information and belief, which I believe to be true. I would be prepared to testify to the above statements based on my personal knowledge and belief.”
IV. Background information
General information (age, occupation, education, family composition etc.)
Past medical history
Review of prior clinical evaluations of torture or ill‑treatment
Psychosocial history pre-arrest.
V. Allegations of torture or ill‑treatment
1. Summary of detention and abuse
2. Circumstances of arrest and detention
3. Initial and subsequent places of detention (chronology, transportation and detention conditions)
4. Narrative account of ill‑treatment or torture (in each place of detention)
5. Review of torture methods.
VI. Physical symptoms and disabilities
Describe the development of acute and chronic symptoms and disabilities and the subsequent healing processes.
1. Acute symptoms and disabilities
2. Chronic symptoms and disabilities
VII. Physical examination
1. General appearance
2. Skin
3. Face and head
4. Eyes, ears, nose and throat
5. Oral cavity and teeth
6. Chest and abdomen (including vital signs)
7. Genito-urinary system
8. Musculoskeletal system
9. Central and peripheral nervous system.
VIII. Psychosocial history/examination
1. Methods of assessment
2. Current psychological complaints
3. Post-torture history
4. Pre-torture history
5. Past psychological/psychiatric history
6. Substance use and abuse history
7. Mental status examination
8. Assessment of social functioning
9. Psychological testing
10. Neuropsychological testing
IX. Photographs and body diagrams
X. Diagnostic test results (see paras. 480–484 abovefor indications and limitations)
XI. Consultations
XII. Interpretation of findings
1. Physical evidence
A. Correlate the degree of consistency between the history of acute and chronic physical symptoms and disabilities with allegations of abuse.
B. Correlate the degree of consistency between physical examination findings and allegations of abuse. (Note: the absence of physical findings does not exclude the possibility that torture or ill‑treatment was inflicted.)
C. Correlate the degree of consistency between examination findings of the individual with knowledge of torture methods and their common after-effects used in a particular region.
2. Psychological evidence
A. Correlate the degree of consistency between the psychological findings and the report of alleged torture.
B. Provide an assessment of whether the psychological findings are expected or typical reactions to extreme stress within the cultural and social context of the individual.
Indicate the status of the individual in the fluctuating course of trauma-related mental disorders over time, that is what is the time frame in relation to the torture events and where in the course of recovery is the individual?
D. Identify any coexisting stressors impinging on the individual (e.g. ongoing persecution, forced migration, exile, and loss of family or social role) and the impact that these may have on the individual.
E. Mention physical conditions that may contribute to the clinical picture, especially with regard to possible evidence of head injury sustained during torture or detention.
XIII. Conclusions and recommendations
1. Statement of opinion on the consistency between all sources of evidence cited above (physical and psychological findings, historical information, photographic findings, diagnostic test results, knowledge of regional practices of torture, consultation reports etc.) and allegations of torture or ill‑treatment.
2. Reiterate the symptoms and disabilities from which the individual continues to suffer as a result of the alleged abuse.
3. Provide any recommendations for further evaluation and care for the individual.
XIV. Statement of truthfulness (for judicial testimony)
For example: “I declare under penalty of perjury, pursuant to the laws of [country], that the foregoing is true and correct and that this affidavit was executed on [date] at [city], [state or province].”
XV. Statement of restrictions on the clinical evaluation/investigation (for subjects in custody)
For example: “The undersigned clinicians personally certify that they were allowed to work freely and independently and permitted to speak with and examine [the subject] in private, without any restriction or reservation, and without any form of coercion being used by the detaining authorities”; or “The undersigned clinician(s) had to carry out his/her/their evaluation with the following restrictions: ...........”
XVI. Clinician’s signature, date and place
XVII. Relevant annexes
A copy of the clinician’s curriculum vitae, anatomical drawings for identification of torture and/or ill‑treatment, photographs, consultations and diagnostic test results, among others.
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