Joint Hypermobility Assessment Form
Please complete this form to help us assess and document any joint hypermobility-related concerns you may have.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Contact Email
*
example@example.com
Have you ever been diagnosed with joint hypermobility or Ehlers-Danlos Syndrome?
*
Yes
No
Not sure
Do you experience frequent joint pain, dislocations, or subluxations (partial dislocations)?
*
Frequently
Occasionally
Rarely
Never
Please rate your overall joint flexibility.
*
1
2
3
4
5
How would you describe your ability to perform daily activities despite joint symptoms?
*
No difficulty
1
2
3
4
Severe difficulty
5
1 is No difficulty, 5 is Severe difficulty
Family history: Has anyone in your family been diagnosed with joint hypermobility or related connective tissue disorders?
*
Yes
No
Not sure
Please indicate if you have experienced any of the following symptoms (select all that apply):
*
Joint pain
Joint instability
Frequent sprains
Skin that stretches easily
Easy bruising
Chronic fatigue
None of the above
Other
Please indicate your ability to perform the following movements (select the option that best describes your ability for each):
*
Rows
Easily
With some effort
Cannot perform
Touch the floor with palms while keeping knees straight
1
2
3
Bend your thumb to touch your forearm
4
5
6
Extend your elbow beyond 10 degrees
7
8
9
Extend your knee beyond 10 degrees
10
11
12
Bend your little finger backwards beyond 90 degrees
13
14
15
Submit Assessment
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