HIP T-SHEET
R 
L 
CC:
Hip Pain
HPI:
Onset:
Mechanism of injury:
Location:
Groin 
Radiation:
Yes 
Exacerbating factors:
Relieving factors:
Both 
Posterior 
Lateral 
No 
Where:
ROS:
Fever  Chills 
Weakness  Night Pain 
Numbness  Paresthesias 
Weight Loss 
Amount_________
PMHx:
Prior malignancy: Yes  No 
Meds:
Hx of back problems: Yes  No  Allergies:
Chronic medical conditions:
Immunizations Current: Yes  No 
Soc Hx:
Occupation and/or Activities:
Smoking status: Current  Past  Never 
IV Drug Use:
Yes  No 
PE:
General Appearance:
Gait:
Normal 
Skin:
Redness
Yes  No 
Location:
Warmth
Yes  No 
Location:
Ulcers
Yes  No 
Location:
Distal Hair pattern:
Normal 
Decreased 
Right
Vascular:
Neuro:
ROM:
Antalgic 
Unable to bear weight 
Femoral Pulse: Nl   
Dorsalis Pedis Pulse: Nl   
Post Tibialis Pulse: Nl   
Capillary Refill:
Normal 
Left
Absent 
Absent 
Absent 
Slow 
Nl   
Nl   
Nl   
Normal 
Absent 
Absent 
Absent 
Slow 
Painful 
Painful 
Painful 
Painful 
Nl 
Nl 
Nl 
Nl 
Painful 
Painful 
Painful 
Painful 
Straight Leg Raise:
Knee Jerk Reflex (L4):
Toe Raise (L5):
Ankle Jerk (S1):
2-point discrimination:
Internal Rotation: Nl   
External Rotation: Nl   
Flexion: Nl   
Extension: Nl   
Active Eval:
SI Joint (FABER):
Impingement (McCarthy):
Soft Tissue:
(Palpation)
Palpable Lymph Nodes:
Lateral Hip (tender):
Hernia:
Testicular Exam:




Nl  Painful 
Nl  Painful 
Nl  Painful 
Nl  Painful 
Yes  No 
Yes  No 
Yes  No 
Nl  Abnormal 
Yes  No 
Yes  No 
Yes  No 
Nl  Abnormal 
TREAT APPROPRIATELY
Trochanteric Bursitis ................... 726.5
Osteoarthritis ............................ 715.95
ITB Syndrome ............................ 728.89
SI Joint Pain ............................... 719.45
Sprain/Strain ............................... 843.x
Low Back Pain ............................. 724.2
TREAT WITH CLOSE
FOLLOW-UP
Soft Tissue
CALL CONSULTATNT
THAT DAY
Can’t walk
AVN
Fracture
CONSULT
OR
REFER
OA, failed conservative treatment
Suspected fracture
Diagnosis unknown
Plan:
 Xray / Imaging
 Laboratory Eval
 NSAIDs
 Acetaminophen
 Other
 PRICE Protocol
 Physical Therapy
Disposition:
 Treatment initiated: Follow-up __________ weeks
 Treatment / Work up Initiated: Follow-up ≤ 1 week __________ days
 Immediate call to Dr.
 Consultation initiated with Dr.
 Referral to Dr.