Limb Extension Range Of Motion Log Form
Record and track limb extension range of motion measurements for clinical or rehabilitation purposes.
Patient Initials
*
Date of Measurement
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Session Number
Limb
*
Please Select
Left Arm
Right Arm
Left Leg
Right Leg
Movement Type
*
Please Select
Flexion
Extension
Abduction
Adduction
Rotation
Other
Measured Angle (degrees)
*
Measurement Method
Please Select
Goniometer
Inclinometer
Visual Estimate
Other
Pain Level During Movement (0 = none, 10 = worst)
No Pain
0
1
2
3
4
5
6
7
8
9
Worst Pain
10
0 is No Pain, 10 is Worst Pain
Therapist/Clinician Name
Additional Notes
Submit Log Entry
Should be Empty: