First Name(Required)Last Name(Required)Phone Number(Required)Email(Required) Zip Code(Required)Name of Child(Required)Has your child ever been a patient of the Medical City Children’s Orthopedics and Spine Specialists? Yes No How old is your child 0 to 4 years of age 5 to 12 years of age 12 to 18 years of age Are any of these activities difficult for your child to perform? Standing Walking Climbing stairs Getting up from a chair/bed Bending Lying down Getting in/out of a car/bathtub Putting on socks/shoes Resting Weight Bearing None of the above Does your child have pain, swelling, aching or stiffness in his or her hip? Yes No Does your child walk or run differently than other kids? Yes No Has your child sustained an accident, injury or trauma to his or her hip resulting in pain or a limp? Yes No Oftentimes an injury needs an evaluation by a physician to determine if there is a fracture/broken bone or muscle injury. Call for an appointment. Does your child have back or knee pain in addition to hip pain or a limp? Yes No Sometimes a problems in the hip results in pain in the knee. Also, sometimes a problem in the back results in pain in the hip. We call this phenomenon referred pain. Call for an appointment.Has your child had a fever, weight loss, or recent illness in addition to hip pain? Yes no Sometimes hip pain can be associated with an infection of the bone, muscles, or skin. We can help determine if there is an infection or inflammation in the hip from a recent infection. Call for an appointment.Has your child ever had an x-ray, CT scan or MRI Scan of his or her hip? Yes No Has your child been treated by a Physical Therapist for hip pain or discomfort within the past year? Yes No Has your child taken any prescription medication for your pain? Yes No Has your child ever received any injections for the hip pain? Yes No Have you seen an orthopedic surgeon about your child’s condition? Yes No Is this a request for a second opinion by a pediatric orthopedist? Yes No
