Hip Fracture Assessment Form
Use this form to record a comprehensive hip fracture assessment, including injury details, symptoms, mobility, relevant medical history, examination findings, imaging, and disposition.
Patient and Incident Details
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Age
Sex / Gender
*
Female
Male
Intersex
Another identity
Prefer not to say
Date and Time of Injury
*
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location or Setting of Injury
Mechanism of Injury
*
Fall from standing
Fall from height
Sports injury
Road traffic injury
Unknown
Other
Symptoms and Clinical Presentation
Pain Severity
*
No pain
1
2
3
4
5
6
7
8
9
Worst pain
10
1 is No pain, 10 is Worst pain
Pain Location
*
Left hip
Right hip
Groin
Thigh
Buttock
Other
Ability to Bear Weight
*
Able without difficulty
Able with pain
Able with assistance
Unable to bear weight
Visible Deformity, Swelling, or Bruising
*
None
Mild
Moderate
Severe
Range of Motion Limitation
*
No limitation
Mild limitation
Moderate limitation
Severe limitation
Unable to move
Numbness, Tingling, or Other Symptoms
Numbness
Tingling
Weakness
Spasm
Other
Mobility, Function, and Risk Indicators
Pre-injury mobility
*
Independent
Assisted
Bedbound
Other
Current ability to walk
*
Walks independently
Walks with assistance
Unable to walk
Other
Need for assistance before injury
*
No assistance needed
Needed help with transfers
Needed help with walking
Needed help with daily activities
Other
Use of mobility aids
Cane
Walker
Wheelchair
None
Other
History of recent falls
*
No recent falls
One fall
Multiple falls
Unknown
Other
Osteoporosis or bone fragility history
Yes
No
Unknown
Prior hip fracture
Yes
No
Unknown
Home safety concerns or fall hazards
Medical History and Current Medications
Relevant medical conditions
*
Osteoporosis
Arthritis
Prior stroke
Dementia/cognitive impairment
Diabetes
Cardiovascular disease
Other
Current medications
Uses anticoagulant or blood thinner
*
Yes
No
Unknown
Allergies or adverse reactions
Previous surgery on the affected hip
Yes
No
Unknown
Examination Findings and Assessment Summary
Affected Side
*
Left
Right
Both
Uncertain
Tenderness on Palpation
Present
Absent
Uncertain
Limb Shortening
Present
Absent
Uncertain
External Rotation
Present
Absent
Uncertain
Neurovascular Status of Affected Limb
Intact
Compromised
Unable to Assess
Uncertain
Clinician Impression or Provisional Diagnosis
Clinical Severity / Urgency
Low
1
2
3
4
5
6
7
8
9
Critical
10
1 is Low, 10 is Critical
Imaging, Treatment, and Disposition
Imaging Ordered/Received
X-ray
CT
MRI
None
Other
Imaging Result Summary
Immediate Treatment Provided
Analgesia
Immobilization
Transfer
Surgery Referral
None
Other
Disposition
*
Discharge
Admit
Transfer
Specialist Referral
Pending
Follow-up Instructions
Submit Assessment
Should be Empty: