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Range of Joint Motion Evaluation Chart - Wa

DSHS 13-585A (REV. 03/2014) 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.

13. Elbow 14. Forearm (Pronation – Supination) Left Left Extension 0O Flexion 150O Pronation 80O Supination 80O Degrees Degrees Degrees Degrees Right Right Extension 0O Flexion 150O Pronation 80O Supination 80O Degrees Degrees Degrees Degrees 15. Ankle 16. Ankle (Flexion – Extension) Left Left Inversion 30O Eversion 20O Plantar 40O Dorsal ...

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