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Range of Joint Motion Evaluation Chart
NAME OF PATIENT
CLIENT IDENTIFICATION NUMBER

INSTRUCTIONS: For each affected joint, please indicate the existing limitation of motion by drawing a line(s) on the
figures below, showing the maximum possible range of motion or by notating the chart in degrees. Provide a complete
description of all affected joints in your narrative summary. If range of motion was normal for all joints, please comment in
your narrative summary. If joints which do not appear on this chart are affected, please indicate the degree of limited
motion in your narrative.
1. Back 2. Lateral · flexion
Extension 25° Flexion 00° Left 25° Ri ht 25°

De rees De rees D rees

3. Neck
Extension 60

De rees D rees D rees

5. Neck 6. Hi

De rees D ees De rees D rees

7. Hi flexion 8. Hi adduction
Left Left20° . ht20°
Knee Flexed Knee Extended
100° 100°

De rees D ees
Ri ht Degrees Degrees
Knee flexed Knee Extended
100° 100°

10. Knee flexion

Left 150

DSHS 13-SSSA (REV. 03/2014)

 11. Shoulder {Abduction -Adduction) 12. Shoulder (Rexion - Extension)
,..
-· Abduction 150°
Left
Adduction 30u Extension 50°
Left
Flexion 150°

\
· .dY
n..nrees D,.,,rees Degrees Degrees
Right Right

.,. ... Abduction 150° Adduction 30u Extension sou Flexion 150°

. Deorees Dearees Dearees Dearees

-
13. Elbow 14. Forearm (Pronation - Supination)
Left Left
Extension o0 Flexion 150° - Pronation 80° Supination 80°

) - Dearees

Extension o0
Right
Dearees

Flexion 150°
Ltf"- Degrees

Pronation 80°
Right
Dearees

Supination 80°

Dearees Degrees Degrees Dearees

iJ·
15.' Ankle ,',
16. Ankle (Flexion - Extension

-
Left Left
Dorsal 20v
,.....,
lnverslon 30° Eversion 20° Plantar 40u

f>-
I ,-
......
t.:':'~__..._
,,....
"'
,.,,\.-
'\
'\ .)....
-
Dearees o - rees Dearees Dearees
Right Right
Inversion 30° Eversion 20v lf Plantar 40v Dorsal 20v

w
Dearees Dearees Degrees Dearees
17. Wrist (radial, ulnar) 18. Wrist
Left Left

1r
Radial 20u Ulnar 30u Extension sou Flexion60u

Degrees De.:irees Deorees Dearees

Ki ht RiJht
m•~

Radial Ulnar
Radial 20° Ulnar '3JJ0 I - Extension 50v Flexion60u

Dearees De.:irees Degrees Dearees

19. ThumbJMP Joiritl " 20. Thumb (IP Joint)
Left Riaht
I Flexion60° Flexion 60°
Left
Flexion 80°
Riaht
Fle:xion 80°

-~ Dearees Dearees
l Degrees Degrees

DATE OF EXAMINATION EXAMINING PHYSICIAN'S SIGNATURE DATE OF REPORT

DSHS 13-585A (REV. 03/2014)