Range Of Joint Motion Evaluation Chart
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1
2Range 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)
O
O
O
O
Extension 25
Flexion 90
Left 25
Right 25
Degrees
Degrees
Degrees
Degrees
3. Neck
4. Neck (lateral bending)
O
O
O
O
Extension 60
Flexion 50
Left 45
Right 45
Degrees
Degrees
Degrees
Degrees
5. Neck (rotation)
6. Hip (backward extension)
O
O
O
O
Left 80
Right 80
Left 30
Right 30
Degrees
Degrees
Degrees
Degrees
7. Hip (flexion)
8. Hip (adduction)
O
O
Left
Left 20
Right 20
Knee Flexed
Knee Extended
O
O
100
100
Degrees
Degrees
Degrees
Degrees
Right
Knee Flexed
Knee Extended
O
O
100
100
Degrees
Degrees
9. Hip (abduction)
10. Knee (flexion)
O
O
O
O
Left 40
Right 40
Left 150
Right 150
Degrees
Degrees
Degrees
Degrees
DSHS 13-585A (REV. 03/2014)
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Parent category: Medical