|
New patient
|
F/U
|
|
Est pt/new problem
|
2nd Opinion
|
|
PCP
|
RHD/LHD
|
|
Hip complaint
• • •
|
Associated CC
• • •
|
|
DOI/onset of pain
• • •
|
DOI Comment
|
|
Specific injury [+]
|
Specific injury [-]
|
|
MOI [+]
• • •
|
MOI comment
|
|
Result of MOI
• • •
|
|
|
Exacerbations [+]
• • •
|
Exacerbation comment
|
|
Alleviating factors [+]
• • •
|
Alleviating factors comments
|
|
Onset/Timing
|
|
|
Severity
|
Severity scale
• • •
|
|
Nature of pain
• • •
|
|
|
NIght time pain [+]
|
Nightime pain [-]
|
|
Swelling [-]
|
Swelling [+]
|
|
Instability [-]
|
Instability [+]
|
|
Giving Way [-]
|
Giving Way [+]
|
|
Previous treatment [-]
|
Previous treatment [+]
• • •
|
|
Previous treatment results
|
Previous treatment comments
|
|
Limitation [-]
|
Limitation [+]
|
|
Previous surgery
|
Type of surgery
• • •
|
|
Date of surgery
|
Surgery comment
|
|
Physical Exam
|
R/L/B Hip
|
|
Gait [-]
|
Gait [+]
• • •
|
|
Skin [-]
|
Skin [+]
• • •
|
|
Skin comment
|
|
|
LLD [-]
|
LLD[+]
|
|
LLD measure longer
|
LLD measure shorter
|
|
Palpation [-]
|
Palpation [+]
• • •
|
|
Palpation comment
|
Palpation abnormality
|
|
ROM [-]
|
ROM [+]
|
|
ROM Extension
|
ROM Flexion
|
|
ROM IR
|
ROM ER
|
|
ROM Abduction
|
ROM comment
|
|
Pain with ROM [-]
|
Pain with ROM [+]
• • •
|
|
Crepitus [-]
|
Crepitus [+]
|
|
Popping/clicking (-)
|
Popping/clicking (+)
|
|
Motor exam [-]
|
Motor exam [+]
|
|
Motor comment
|
Motor grade
|
|
Sensory exam [-]
|
Sensory exam [+]
• • •
|
|
Sensory comment
|
|
|
DP pulse [-]
|
DP pulse [+]
|
