Back Hyperextension Assessment Form
Complete this form to assess back hyperextension performance and related factors in a clinical or fitness setting.
Participant Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
How would you rate your current back discomfort before the assessment?
*
1
2
3
4
5
6
7
8
9
10
Did you experience any pain during the back hyperextension movement?
*
No pain
Mild pain
Moderate pain
Severe pain
Location of any pain or discomfort (select all that apply)
Lower back
Middle back
Upper back
Glutes
Hamstrings
Other
Rate your perceived effort during the back hyperextension exercise.
*
Very easy
1
2
3
4
5
6
7
8
9
Very hard
10
1 is Very easy, 10 is Very hard
How would you describe your range of motion during the hyperextension?
*
Full range
Slightly limited
Moderately limited
Severely limited
Assessment of Movement Quality
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Movement was smooth
1
2
3
4
5
No compensatory movements observed
6
7
8
9
10
Proper alignment maintained throughout
11
12
13
14
15
Controlled movement speed
16
17
18
19
20
Observations or comments (optional)
Would you recommend any modifications or further evaluation?
No modifications needed
Minor modifications
Major modifications
Further clinical evaluation recommended
Submit Assessment
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