Inguinal Canal Examination Form
Complete this form to document an inguinal canal examination, associated symptoms, findings, and follow-up recommendations.
Patient & Visit Details
Patient name
*
First Name
Middle Name
Last Name
Date of birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Sex / gender
Please Select
Female
Male
Intersex
Non-binary
Prefer to self-describe
Prefer not to say
Visit date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring clinician or department
Reason for examination
*
Symptoms & History
Chief complaint
*
Symptom onset or duration
Side affected
*
Left
Right
Bilateral
Unclear
Pain severity
1
2
3
4
5
6
7
8
9
10
Groin bulge present
Yes
No
Intermittent
Unsure
Change with coughing or straining
Worse
No change
Improves
Unsure
Relevant prior history
Examination Findings
Inspection result
*
Normal
Visible bulge
Swelling without bulge
Asymmetry
Other
Palpation / tenderness
*
No tenderness
Mild tenderness
Moderate tenderness
Marked tenderness
Not assessed
Cough impulse
Present
Absent
Equivocal
Not assessed
Reducibility
Fully reducible
Partially reducible
Not reducible
Not assessed
Bulge size (cm)
Associated extension
Scrotal extension
Groin extension
Bilateral findings
Other
Other notable examination observations
Assessment & Plan
Preliminary Impression / Diagnosis
*
Recommended Next Steps
*
Observation
Further imaging
Laboratory tests
Specialist referral
Surgical consultation
Conservative management
Other
Urgency / Follow-up Timing
*
Please Select
Urgent today
Within 1 week
Within 2–4 weeks
Routine follow-up
As needed
Treatment / Referral Recommendation
*
No immediate treatment
Medication management
Activity modification
Referral to general surgery
Referral to another specialist
Other
Clinician Notes
Submit
Should be Empty: