Hip Extension Measurement Form
Document hip extension measurements and related assessment details.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
example@example.com
Side Measured
*
Left
Right
Both
Measurement Method
*
Please Select
Goniometer
Visual Estimation
Inclinometer
Other
Hip Extension Measurement (degrees)
*
Rows
Degrees
Left Hip
Right Hip
Pain Level During Movement
No Pain
0
1
2
3
4
5
6
7
8
9
Severe Pain
10
0 is No Pain, 10 is Severe Pain
Observed Functional Limitations
Decreased range of motion
Pain during movement
Muscle weakness
No limitation observed
Other
Additional Notes or Observations
Assessor Name
*
First Name
Last Name
Submit Measurement
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