Range Of Motion

Evaluation Progress

1.Neck movement Act. Pas. Act. Pas. Act. Pas. Act. Pas.
Extension
(60 degrees)
Flexion
(50 degrees)

Side flexion L
(45 degrees)
R

Rotation L
(80 degrees)
R
DATE:

Evalua Evaluation Progress

2. Shoulder Movement Act. Pas. Act. Pas. Act. Pas.

Flexion
(0 - 180 degrees)
Extension
(0 - 60 degrees)
Abduction
(0 - 140 degrees)
Adduction
(0 - 45 degrees)
External rotation
(0 - 90 degrees)
Internal rotation
(0 - 90 degrees)
L R L R L R L R L R L R
DATE:
 Evaluation Progress

3. Elbow Movements Act. Pas. Act. Pas. Act. Pas.

Flexion
(0 - 150 degrees)
Extension
(0 degrees)
Forearm Pronation
(0 - 80 degrees)
Forearm Supination
(0 - 80 degrees)
L R L R L R L R L R L R
DATE:

Evaluation Progress

4. W/H Movements Act. Pas. Act. Pas. Act. Pas.

Flexion
(0 - 80 degrees)
Extension
(0 - 70 degrees)
Radial Deviation
(0 - 20 degrees)
Ulnar Deviation
(0 - 30 degrees)
Thumb Flexion (MP Joint)
(0 - 60 degrees)
Thumb Flexion (IP Joint)
(0 - 80 Degrees)
L R L R L R L R L R L R
DATE:

Evaluation Progress

5. Hip Movements Act. Pas. Act. Pas. Act. Pas

Flexion
(0 - 120 degrees)
Extension
(0 - 30 degrees)
Abduction
(0 - 45 degrees)
Adduction
(0 -30 degrees)
Lateral Rotation
(0 - 45 degrees)
Medial Rotation
(0 - 45 degrees)
L R L R L R L R L R L R
DATE:
6. Knee Movements Act. Pas. Act. Pas. Act. Pas.
Flexion
(0 - 135+ degrees)
L R L R L R L R L R L R
DATE:

7. Ankle / Foot Movement Act Pas Act Pas Act Pas

Dorsi-flexion
(0 - 20 degrees)
Plantar-flexion
(0 - 50 degrees)
Inversion
(0 - 35 degrees)
Eversion
(0 - 15 degrees)
L R L R L R L R L R L R
DATE:

Patient`s name: _____________________________________

Diagnosis: ______________________________________

Physiotherapist signature: ______________________________