Shoulder 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 shoulder extension (50°) adduction (40°-50°) internal rotation (80°-90°) Left shoulder -0-0- flexion (180°) abduction (170°-180°) external rotation (60°-90°) extension (50°) adduction (40°-50°) internal rotation (80°-90°) -0-0- flexion (180°) abduction (170°-180°) external rotation (60°-90°) -0- -0- Examining physician name and title (please print or type): Signature: Date of examination: 440-4842 (6/10/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com