Ankle Dorsiflexion Range of Motion Assessment Form
Ankle Dorsiflexion Range of Motion Assessment Form
Which ankle is being assessed?
*
Left
Right
Both
Assessment position used
*
Non-weight bearing (supine)
Weight bearing (standing lunge)
Other
Measurement method
*
Goniometer
Inclinometer
Visual estimation
Other
Dorsiflexion range (degrees)
*
Is dorsiflexion limited compared to normal?
*
No limitation
Mild limitation
Moderate limitation
Severe limitation
Pain during dorsiflexion?
*
No pain
Mild pain
Moderate pain
Severe pain
Functional impact of limitation
*
1
2
3
4
5
Symmetry comparison
*
Rows
Left Ankle
Right Ankle
Normal
1
2
Reduced
3
4
Painful
5
6
Not assessed
7
8
Notes or observations
Overall assessment
*
Normal
Mild impairment
Moderate impairment
Severe impairment
Submit Assessment
Should be Empty: