HIP Appearance* Normal Swelling Redness Erythema Deformity Scars OtherPalpation* 1. Greater Trochanter R L 2. Pubis R L 3. Ilia R L 4. Other Observed Abnormality? Yes No Sensation Intact? Yes No Moves Extremities w/o Deficit? Yes No Strength 1 2 3 4 5 Range of MotionFlexion Full Limited LevelPainPlease enter a number from 0 to 10.ExplainExtension Full Limited LevelPainPlease enter a number from 0 to 10.ExplainAvduction Full Limited LevelPainPlease enter a number from 0 to 10.ExplainAduction Full Limited LevelPainPlease enter a number from 0 to 10.ExplainInternal Rotation Full Limited LevelPainPlease enter a number from 0 to 10.ExplainExternal Rotation Full Limited LevelPainPlease enter a number from 0 to 10.ExplainProcedure Note Consent Skin Cleaned with Chlohexadine Other Tender Points Injected with: Dextrose PRP Joint Injection: Dextrose PRP Stem Cell Resolution of Symptoms? Yes No Tolerated Well? Yes No Medication 1AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDoseMedication 2AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDoseMedication 3AtivanDilaudidDemerolFentanylKetamineMorphineValiumVerscelDose
