ORTHOGENIE

doctor name

LOREM IPSUM

HIP AND PELVIS CASE SHEET

(1ST SESSION OR SIMULTANEOUS 2 SESSIONS)

EMAIL ADDRESS

PERSONAL DATA

NAME OF THE PT ( رباعى بالعربى )

NATIONAL ID

PREOPERATIVE NEUROLOGICAL STATUS

(SCIATIC N INJURY(IF INJURED ..DESCRIBE IN OTHERS

INTACT

INJURY

other

OTHER PREOP NERVE INJURIES

PREOPERATIVE HB

MEDICAL CO-MORBID

	D.M	HTN	HEPATIC	CARDIAC	VIROLOGY
CONTROLLED
UNCONTROLLED

PREOP SOFT TISSUE STATUS

(MOREL LAVALLEE LESION(IF PRESENT,DESCRIBE IN OTHERS

PRESENT

ABSENT

other

ACETABULUM

(DIAGNOSIS( ACETABULUM

yes

F:ACETABULUM

(DIAGNOSIS( ACETAULUM

	PW	PC	AW	AC	TRANSVERSE	TRPW	PWPC
lt
rt

DISLOCATION
(COMPLETE LOSS OF RELATION BETWEEN THE HEAD AND DOME)

	POSTERIOR	CENTRAL	ANTERIOR	NONE
CONTROLLED
UNCONTROLLED