Cervical Spine Range of Motion Assessment Form
Use this form to document cervical spine range of motion findings, pain, and related assessment notes.
Assessment Details
Assessment date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor name
*
Assessment setting / site
Please Select
Clinic
Hospital
Home visit
Telehealth
Other
Reason for assessment / primary concern
*
Cervical Motion Findings
Cervical Range of Motion Measurements
*
Rows
Active ROM (°)
Passive ROM (°)
Pain During Movement
Restriction / End-Feel Notes
Flexion
Extension
Left Lateral Flexion
Right Lateral Flexion
Left Rotation
Right Rotation
Additional Cervical Motion Observations
Movements with Limited Active Range
Flexion
Extension
Left Lateral Flexion
Right Lateral Flexion
Left Rotation
Right Rotation
None
Notes on Compensatory Motion or Guarding
Symptoms and Functional Impact
Pain at Rest
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Pain With Movement
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Submit Assessment
Should be Empty: