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INSTRUCTIONS: For each affected joint, indicate the amount of motion acheived.
1. Back Extension 25
Flexion 90
Right 25
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3. Neck Extension 60
Flexion 50
Right 45
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Right 80
Right 30
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Right 20
Degrees Right
Knee Flexed 100
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Knee Extended 100
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Abduction 150
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Adduction 30
Degrees Right
Extension 50
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Flexion 150
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Flexion 150
Pronation 80
Supination 80
Degrees Right
Extension 0
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Flexion 150
Degrees Right
Pronation 80
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Supination 80
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Eversion 20
Dorsal 20
Degrees Right
Inversion 30
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Eversion 20
Degrees Right
Plantar 40
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Dorsal 20
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Ulnar 30
Flexion 60
Degrees Right
Radial 20
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Ulnar 30
Degrees Right
Extension 60
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Flexion 60
Degrees Right
Flexion 60
Degrees Right
Flexion 80
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DATE OF EXAMINATION
PROVIDER's SIGNATURE