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Lower Extremity Range of Motion Worker's name: DOI: WCD #: Range of motion: Report active range of motion in degrees of any joints applicable and the corresponding contralateral joint, if contralateral has no history of injury or disease. The values in parentheses are the norms established by the Department of Consumer and Business Services. Right hip extension (30°) adduction (20°) internal rotation (40°) Left hip -0-0-0- flexion (100°) external rotation (50°) extension (30°) internal rotation (40°) -0-0-0- flexion (100°) abduction (40°) external rotation (50°) abduction (40°) adduction (20°) Right knee extension (0°) -0flexion (150°) Left knee extension (0°) -0flexion (150°) Right ankle dorsiflexion (20°) eversion (20°) Left ankle -0-0- plantar flexion (40°) inversion (30°) dorsiflexion (20°) eversion (20°) -0-0- plantar flexion (40°) inversion (30°) Right foot (digits) Great toe flexion dorsi IP MP 2nd toe plantar dorsi -0-0- 3rd toe plantar dorsi -0-0- 4th toe plantar dorsi -0-0- 5th toe plantar -0-0- plantar dorsi -0-0- Left foot (digits) Great toe flexion dorsi IP MP 2nd toe plantar dorsi -0-0- 3rd toe plantar dorsi -0-0- 4th toe plantar dorsi -0-0- 5th toe plantar -0-0- plantar dorsi -0-0- Examining physician name and title (please print or type): Signature: 440-4841 (6/10/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Date of examination:
