DSHS 13-585A (REV. 03/2014) Range of Joint Motion Evaluation Chart NAME OF PATIENT CLIENT IDENTIFICATION NUMBER INSTRUCTIONS: For each affected joint,...
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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 25O
Flexion 90O
Left 25O
Right 25O
Degrees
Degrees
Degrees
Degrees
3. Neck
4. Neck (lateral bending)
Extension 60O
Flexion 50O
Left 45O
Right 45O
Degrees
Degrees
Degrees
Degrees
5. Neck (rotation)
6. Hip (backward extension)
Left 80O
Right 80O
Left 30O
Right 30O
Degrees
Degrees
Degrees
Degrees
7. Hip (flexion)
8. Hip (adduction) Left
Knee Flexed O 100
Degrees
Right 20O
Degrees
Degrees
Degrees Right
Knee Flexed O 100
Knee Extended O 100
Degrees
Degrees
9. Hip (abduction)
DSHS 13-585A (REV. 03/2014)
Left 20O
Knee Extended O 100
10. Knee (flexion)
Left 40O
Right 40O
Left 150O
Right 150O
Degrees
Degrees
Degrees
Degrees
11. Shoulder (Abduction – Adduction)
12. Shoulder (Flexion – Extension)
Left O Abduction 150 Adduction 30O Degrees
Degrees Right O Abduction 150 Adduction 30O Degrees
