Knee Range of Motion Measurement Form
Document knee range of motion assessment for clinical evaluation and follow-up.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which knee is being assessed?
*
Left
Right
Both
Type of Measurement Tool Used
*
Please Select
Goniometer
Manual Estimation
Digital Device
Other
Knee Range of Motion Measurements (Degrees)
*
Rows
Flexion
Extension
Hyperextension
Left Knee
Right Knee
Pain Level During Measurement
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Patient-reported symptoms or limitations
Clinical Notes / Observations
Examiner Name and Title
*
Signature of Examiner or Patient (if required)
Submit Measurement
Submit Measurement
Should be Empty: