Category III - Pain/Other Symptoms/Impairment Information

3
Name:

[claimant_name]

CASENBR: [case_id#]

Examiner: [case_owner_desk_name]

RANGE OF MOTION REPORT FORM
(All range of motion measurements should be active motion.)
MOTION

NORMAL RANGE

CERVICAL SPINE
Forward Flexion
Extension

0o

PATIENT’S RANGE
RIGHT

-

50o

0o - 60o

Lateral Flexion

0o - 45o

Rotation

0o - 80o

LUMBAR SPINE
Forward Flexion
Extension
Lateral Flexion

0o - 90o
0o - 25o
0o - 25o

SHOULDER
Flexion
Extension

0o - 180o

Abduction

0o - 170o

Adduction

0o - 40o

External Rotation

0o - 60o

Internal Rotation

0o - 80o

ELBOW

pg. 1

Flexion
Extension

0 o - 50°

0o - 140o
0°

Pronation

0o - 80o

Supination

0o - 80o

LEFT

ANKYLOSED AT
(if applicable)
RIGHT
LEFT

Name:

[claimant_name]

WRIST

CASENBR: [case_id#]

0o - 60o
Dorsiflexion
Palmar Flexion

0o - 60o

Ulnar Deviation

0o - 30o

Radial Deviation

0o - 20o

HAND
THUMB Adduction CMC joint ≤ 2cm

INDEX

Abduction CMC joint

0 o - 50 o

Flexion MCP joint

0 o - 60o

Flexion IP joint

0o - 80o

Flexion MCP joint

0o - 90o

Flexion PIP joint

0o - 100o

Flexion DIP joint

0o - 70o

MIDDLE Flexion MCP joint

0o - 90o

Flexion PIP joint

0o - 100o

Flexion DIP joint

0o - 70o

Flexion MCP joint

0o - 90o

Flexion PIP joint

0o - 100o

Flexion DIP joint

0o - 70o

LITTLE Flexion MCP joint

0o - 90o

RING

Flexion PIP joint

0o - 100o

Flexion DIP joint

0o - 70o

HIP

0o - 100o
Flexion

pg. 2

Examiner: [case_owner_desk_name]

KNEE

ANKLE

Extension

0o - 10o

Abduction

0o - 25o

Adduction

0o - 15o

Internal Rotation

0o - 20o

External Rotation

0o - 30o

Flexion
Extension
Dorsiflexion
Plantar Flexion

0o - 110o
0 o - 5o
0o - 10o
0o - 20o

Inversion

0o - 30o

Eversion

0o - 15o
Page 2 of 3

HALLUX
0o - 30o
Dorsiflexion MTP joint
Plantar flexion MTP
0o - 30o
joint
Flexion IP Joint
0o - 20o

DESCRIBE STRAIGHT LEG RAISING: (supine and seated)

DESCRIBE GAIT AND STATION: If an assistive device is used for ambulation, comment on
its medical necessity and the patient's ability to walk without it.

DESCRIBE DEXTERITY: Include observation of ability to pinch, grasp and manipulate small
and large objects. Please comment on the presence of any deformities or contractures of the
hands. Is claimant able to make a fully closed fist? Can the fingers be opposed?
Grip Strength (0-5/5): Left: 0 1 2 3 4 5
pg. 3

Right: 0 1 2 3 4 5

EFFORT ON EXAM:

GOOD ____ FAIR ____

_____________________________________
SIGNATURE

pg. 4

POOR ____

_____________________________________
DATE