Degree of Freedom Assessment
Please complete this form to assess your range of motion and mobility. Answer each section as accurately as possible.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
*
Please rate your ability to perform the following movements without discomfort:
*
Rows
No Difficulty
Mild Difficulty
Moderate Difficulty
Severe Difficulty
Unable to Perform
Neck rotation
1
2
3
4
5
Shoulder abduction
6
7
8
9
10
Elbow flexion
11
12
13
14
15
Wrist extension
16
17
18
19
20
Hip flexion
21
22
23
24
25
Knee extension
26
27
28
29
30
Ankle dorsiflexion
31
32
33
34
35
Do you experience pain during any of these movements?
*
No pain
Mild pain
Moderate pain
Severe pain
Pain prevents movement
Please indicate which areas you experience pain or stiffness (select all that apply):
Neck
Shoulders
Back
Elbows
Wrists/Hands
Hips
Knees
Ankles/Feet
Other
Have you had any previous injuries or surgeries that affect your movement?
*
No
Yes, injuries
Yes, surgeries
Yes, both injuries and surgeries
How would you rate your overall flexibility?
*
1
2
3
4
5
How would you rate your overall mobility?
*
1
2
3
4
5
Please describe any additional comments, concerns, or goals related to your mobility or range of motion:
Signature (please sign below to confirm your responses and consent)
*
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