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Range of Motion Evaluation Chart

Range of Motion Evaluation Chart

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Published by pmr1964

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Published by: pmr1964 on Jun 19, 2012
Copyright:Attribution Non-commercial

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06/15/2014

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RANGE OF JOINT MOTION EVALUATION CHART
Flexion 90Extension 25Right 25Left 25
3. Neck 4. Neck (lateral bending)
Flexion 50Extension 60Right 45Left 45
5. Neck (rotation)6. Hip (backward extension)
Right 80Left 80Right 30Left 30
7. Hip (flexion)8. Hip (adduction)
Right 20Left 20
9. Hip (abduction)10. Knee (flexion)
Right 40Left 40Left 150
Knee Flexed 100Knee Extended 100
Left
Knee Flexed 100Knee Extended 100
Right
1. Back2. Lateral (flexion)
DegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegreesDegrees
DSHS 13-585A (REV. 08/2002) (AC 01/2003)
NAME OF PATIENT
INSTRUCTIONS:
For each affected joint, please indicate the existing limitation of motion by drawing a line(s) on thefigures below, showing the maximum possible range of motion or by notating the chart in degrees. Provide a completedescription of all affected joints in your narrative summary. If range of motion was normal for all joints, please commentin your narrative summary. If joints which do not appear on this chart are affected, please indicate the degree of limitedmotion in your narrative.
SOCIAL SECURITY NUMBER
Right 150Degrees

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