FORMULIR REGISTRASI FMS

1. Data Pribadi
a. Nama Lengkap :
b. Tempat/ tanggal lahir :
c. Umur :
d. Jenis Kelamin :
e. Sports (Olahraga) :

2. Vital sign
a. Tekanan Darah :
b. Denyut Nadi :
c. Pernafasan :
d. Suhu :
e. Saturasi O2

3. Antropometri
a. Tinggi Badan (Height):
b. Berat Badan (Weight) :
c. Panjang Tangan :
d. Panjang Tungkai :
 The Functional Movement Screen
Scoring Sheet

NAME DATE DOB

ADDRESS

CITY, STATE, ZIP PHONE

SCHOOL/AFFILIATION
FMS

SSN HEIGHT WEIGHT AGE GENDER

PRIMARY SPORT PRIMARY POSITION

HAND/LEG DOMINANCE PREVIOUS TEST SCORE

RAW FINAL
TEST SCORE SCORE COMMENTS

DEEP SQUAT
L
HURDLE STEP
R
L
INLINE LUNGE
R
L
SHOULDER MOBILITY
R
L
IMPINGEMENT CLEARING TEST
R
L
ACTIVE STRAIGHT-LEG RAISE
R
TRUNK STABILITY PUSHUP

PRESS-UP CLEARING TEST

L
ROTARY STABILITY
R
POSTERIOR ROCKING CLEARING TEST
TOTAL

Raw Score: This score is used to denote right and left side scoring. The right and left sides are scored in five of the
seven tests and both are documented in this space.
Final Score: This score is used to denote the overall score for the test. The lowest score for the raw score (each side)
is carried over to give a final score for the test. A person who scores a three on the right and a two on the left would
receive a final score of two. The final score is then summarized and used as a total score.
 FUNCTIONAL MOVEMENT SCREEN SCORING SHEET
DATE: ______________ NAME: ___________________________________ AGE: _______ LEVEL: ____________________

TEAM/SCHOOL: ________________________________ HEIGHT: __________ HAND DOMINAANCE: R L

SPORT/POSITION: ______________________________ WEIGHT: __________ LEG DOMINANCE: R L

TEST SCORE DYSFUNCTION GRADING CRITERIA III GRADING CRITERIA II GRADING CRITERIA I
1. Deep Squat 3 2 1 0 >Upper torso is parallel with >Upper torso is parallel with >Tibia and upper torso are not
tibia or toward vertical tibia or toward vertical parallel
TOE TOUCH TEST: Able >Femur below horizontal >Femur below horizontal >Femur not below horizontal
Not able >Knees aligned over feet >Knees aligned over feet >Knees not aligned over feet
>Dowel aligned over feet >Dowel aligned over feet on a >Lumbar flexion noted
2X4
2. Hurdle Step 3 2 1 0 >The hips, knees & ankles >Alignment is lost between >Contact with foot & hurdle
remain aligned in the sagital hips, knees & ankles >Loss of balance at any time
Inches: ____________ plane >Movement in the lumbar
>Minimal Movement in the spine
Left Leg Up 3 2 1 0 lumbar spine >Dowel & hurdle do not remain
>Dowel & hurdle remain parallel
Right Leg Up 3 2 1 0 parallel
3. In-Line Lunge 3 2 1 0 >Minimal to no torso >Movement noted in torso >Loss of balance at any time
movement >Feet do not remain in sagital
Inches: ____________ >Feet remain in sagital plane plane on the 2X6
on the 2X6 >Knee does not touch 2X6
Left Leg Forward 3 2 1 0 >Knee touches 2X6 behind the behind the heel of front foot
heel of front foot
Right Leg Forward 3 2 1 0
4. Shoulder Mobility 3 2 1 0 >Fists should be within one >Fists should be within one >Fists fall greater than one and
Distance (tip of middle finger to L top: ____ hand length and a half hand lengths a half hand lengths
distal crease): ____________ R top: ____

IMPINGEMENT TESTS SCORE 6.5=9.75, 6.75=10.1, 7.0=10.5,

__________Left 3 2 1 0 7.25=10.86, 7.5=11.25, 7.75=11.63, 8=12,
__________Right 3 2 1 0 8.25=12.38, 8.5=12.75, 8.75=13.1, 9=13.5
5. Active Straight Leg Raise 3 2 1 0 >Malleoi resides between mid- >Malleoi resides between mid- >Malleoi resides below mid-
thigh and ASIS thigh and mid-patella patella
L: ______
R: ______
6. Trunk Stability Push Up 3 2 1 0 >Males perform 1 repetition >Males perform 1 repetition >Males unable to perform 1
with the thumbs above head with thumbs in line with the rep with hands in line with chin
PRONE PRESS UP TEST >Females perform 1 repetition chin >Females unable to perform 1
____________ with thumbs in line with the >Females perform 1 rep with rep with thumbs in line with
chin thumbs in line with the clavicle clavicle
7. Rotary Stability Quadruped 3 2 1 0 >Performs 1 unilateral rep >Performs 1 diagonal rep while >Unable to perform diagonal
while keeping torso parallel to keeping torso parallel to board repetitions
KNEELING LUMBAR board >Knee & elbow touch in line
FLEXION TEST >Knee & elbow touch in line with the board
________________ Left Up 3 2 1 0 with the board

Right Up 3 2 1 0

Total Score Tests 1-7: ____________/21 Initials of Tester: ___________________ Revised 4/15/11