Spinal (Cervical) Range of Motion Worker's name: DOI: WCD #: Use this form to describe range of motion of the spine. Indicate the active range of motion measured in degrees with an inclinometer. Bulletin No. 239 describes the criteria for measuring spinal range of motion using a single fluid-filled inclinometer. A videotape illustrating the use of a single fluid-filled inclinometer is available from the Department of Consumer and Business Services. The values in parentheses under each movement are the norms established by the Department of Consumer and Business Services. PLEASE COMPLETE AND RETURN WITH YOUR REPORT Movement Description Measurements (minimum of three) 1 Cervical flexion (60°) Cervical extension (75°) a. Degrees of cranial flexion....................................................... b. Degrees of T1 flexion............................................................ c. Cervical flexion angle (a minus b).............................................. d. Are measurements within +/- 10% or 5° (whichever is greater)?................... e. Maximum cervical flexion angle ............................................... a. Degrees of cranial extension.................................................... b. Degrees of T1 extension......................................................... c. Cervical extension angle (a minus b)........................................... d. Are measurements within +/- 10% or 5° (whichever is greater)?................... e. Maximum cervical extension angle............................................. a. Degrees of cranial right lateral flexion......................................... b. Degrees of T1 right lateral flexion.............................................. c. Lateral flexion angle (a minus b)............................................... d. Are measurements within +/- 10% or 5° (whichever is greater)?.................... e. Maximum cervical right lateral flexion angle. ................................ a. Degrees of cranial left lateral flexion........................................... b. Degrees of T1 left lateral flexion............................................... c. Lateral flexion angle (a minus b)............................................... d. Are measurements within +/- 10% or 5° (whichever is greater)?................... e. Maximum cervical left lateral flexion angle. ................................. a. Degrees of right cervical rotation.............................................. b. Are measurements within +/- 10% or 5° (whichever is greater)?................... c. Maximum right cervical rotation angle......................................... a. Degrees of left cervical rotation................................................ b. Are measurements within +/- 10% or 5° (whichever is greater)?................... c. Maximum left cervical rotation angle............................................ Yes No 2 Yes No Cervical right 3 lateral flexion (45°) Cervical left Yes No 4 lateral flexion (45°) Cervical right 5 rotation (80°) Yes No Yes No 6 rotation (80°) Cervical left Yes No Examining physician name and title (print or type): Signature: 440-2278C(6/10/DCBS/WCD/WEB) Date of examination: American LegalNet, Inc. www.FormsWorkFlow.com