Pediatric Hip Examination Checklist
Document findings and assessments for pediatric hip evaluation.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Examination Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Examiner Name
*
First Name
Last Name
Relevant Birth History
Risk Factors (select all that apply)
Breech presentation
Family history of hip dysplasia
First-born
Female sex
Oligohydramnios
Other
Clinical Findings
*
Rows
Normal
Abnormal
Not Assessed
Inspection (asymmetry, skin folds)
1
2
3
Palpation (hip clicks, tenderness)
4
5
6
Range of Motion
7
8
9
Leg Length Discrepancy
10
11
12
Specific Hip Tests
*
Rows
Negative
Positive
Not Performed
Ortolani Test
13
14
15
Barlow Test
16
17
18
Galeazzi Sign
19
20
21
Hip Abduction Range
22
23
24
Imaging Recommended
No imaging required
Ultrasound
X-ray
Summary and Impression
Additional Notes
Examiner's Signature
*
Submit Checklist
Submit Checklist
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