COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) -against- : Index No. Spinal Range JUDICIAL SUBPOENA of Motion Calendar No. : : Worker’s name: Date of injury: In describing range of motion of the spine, this form may be used as an :alternative to a narrative format. Indicate the active range of motion of the injured part measured in degrees with an inclinometer. The use of the inclinometer as Defendant(s) : endorsed. by .the .AMA .in.the .Guides.to.the.Evaluation. of. Permanent Impairment, 3rd edition (revised), copyright 1990, ... .. .. .... . .. ..... . .. ........ . ............ is the method of choice for measuring spinal range of motion. Bulletin No. 239 describes the criteria for measuring spinal range of motion using a single fluid-filled inclinometer. A video tape illustrating the use of a single fluid-filled inclinometer is available from the Department of Consumer & Business Services. THE PEOPLE OF THE STATE OF NEW YORK The values in parentheses under each movement are the norms established by the AMA Guides and adopted by the Department of Consumer & Business Services. TO CERVICAL RANGE OF MOTION Movement Description 1 2 3 N/A Measurements (minimum of three) a. Degrees of cranial flexion………………………………………………. GREETINGS: b. Degrees of T1 flexion…………………………………………………... Cervical c. Cervical Flexion COMMANDflexion angle (a minus b)……………….……………………... you WE YOU, within business and excuses greater)?……….……… d. Are measurementsthat all+/- 10% or 5° (whichever is being laid aside, and each of you attend before Yes No (60°) , the Honorable at the Court e. Maximum cervical flexion angle ……………………………………….. located at County of a. Degrees of cranial extension……………………………………………. in room , on the day of , 20 , at o'clock in the noon, and at any recessed b. Degrees of T1 extension………………………………………………... Cervical or adjourned date,c.to testifyextension angle (a minusas a witness in this action on the part of the and give evidence b)…….……………………………... Cervical extension (75°) d. Are measurements within +/- 10% or 5° (whichever is greater)?………………. Yes No e. Maximum cervical extension angle…….……………………………….. a. Degrees of cranial right lateral flexion………………………………….. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Cervical right b. Degrees of T1 right lateral flexion…………………………………….... the party on whose Lateral flexionsubpoena was issued for a maximum penalty of $50 and all damages sustained as a behalf this c. lateralof your failure to comply. angle (a minus b)…………….…………………………. result flexion d. Are measurements within +/- 10% or 5° (whichever is greater)?……………..... Yes No (45°) e. Maximum cervical right lateral flexion angle. ………………….…....… Witness, Honorable , a. Degrees of cranial left lateral flexion…………………………………....one of the Justices of the Cervical left b. Degrees of T1 left lateral flexion…………………………………….…. Court in County, day of , 20 4 lateral flexion (45°) Cervical right 5 rotation (80°) Cervical left 6 rotation (80°) c. Lateral flexion angle (a minus b)…………….…………………………. d. Are measurements within +/- 10% or 5° (whichever is greater)?……….……... Yes No e. Maximum cervical left lateral flexion angle. ………………….……….. (Attorney must sign above and type name below) a. Degrees of right cervical rotation………………………………………. b. Are measurements within +/- 10% or 5° (whichever is greater)?………………. Yes No c. Maximum right cervical rotation angle...……………………………….. Attorney(s) for a. Degrees of left cervical rotation………………………………………… b. Are measurements within +/- 10% or 5° (whichever is greater)?………………. Yes No c. Maximum left cervical rotation angle......………………………...…….. (Thoracic and lumbar on reverse) Examining physician name & title (print or type): Office and P.O. Address Signature: Date of Telephone No.: examination: Facsimile No.: E-Mail Address: Mobile Tel. No.: 440-2278(3/00/DCBS/WCD/WEB) American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : THORACIC RANGE OF MOTION Movement Description 1 Plaintiff(s) : Measurements (minimum JUDICIAL SUBPOENA of three) a. T12 angle compared to T1 (flexed)……………………………………... -against: b. T12 angle compared to T1 (erect) (angle of minimum kyphosis)………. c. Angle of thoracic flexion (a minus b)…………………………………... : d. Are measurements within +/- 10% or 5° (whichever is greater)?……………… e. Maximum thoracic flexion angle……………………………………….. Thoracic Flexion (50°) Thoracic right 2 . . rotation. . . . . ....... (30°) Calendar No. N/A : a. Degrees of right rotation at T1………………………………………….. b. Degrees of right rotation at T12………………………………………… Defendant(s) : c. Thoracic . . . .rotation angle (a.minus b)……………………………….. . . . . . . . . right . . . . . . . . . . . . . . . . . . . . . . . . . . . d. Are measurements within +/- 10% or 5° (whichever is greater)?……………… e. Maximum thoracic right rotation angle…………………………………. Yes No Yes No Yes No a. Degrees of right rotation at T1………………………………………….. THE PEOPLE Thoracic left OFb.THE STATE rotation at T12………………………………………….. Degrees of left OF NEW YORK 3 rotation TO (30°) c. Thoracic left rotation angle (a minus b)………………………………… d. Are measurements within +/- 10% or 5° (whichever is greater)?……………… e. Maximum thoracic left rotation angle…………………………………... LUMBAR RANGE OF MOTION GREETINGS: Movement Description 1 N/A Measurements (minimum of three) a. Degrees of flexion at T12………………………………………….. WE Lumbar COMMAND YOU, that allmidsacrum………………………….……….. you b. Degrees of flexion at business and excuses being laid aside, the Honorable at )……………………………. Court c. True lumbar flexion angle (a minus bthe flexion located at +/- 10% or 5° (whichever is greater)?……….… County of d. Are measurements within (60°) and each of you attend before , Yes No in room , on the , 20 , at o'clock noon, and at any recessed e. Maximum day lumbar flexion angle………………………………. in the true of or adjourned date, to testify and give evidence as a witness in this action on the part of the a. Degrees of extension at T12……………………………………….. 2 Lumbar b. Degrees of extension at midsacrum…………………………….….. c. True lumbar extension angle (a minus b )…………………………. Extension d. Are measurements within +/- 10% or 5° (whichever is greater)?…………. Yes No (25°) failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Your e. Maximum true lumbar extension angle……………………………. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a a. comply. Right straight leg raising (SLR) angle……………………………... result of straight Passive your failure to leg raising right b. Are measurements within +/- 10% or 5° (whichever is greater)?…………. Yes No c. Maximum straight leg raising right………………………………... Witness, Honorable , one of the Justices of the d. Left straight leg raising (SLR) angle………………………………. Passive straight e. Are measurements within +/- 10% or 5° (whichever is greater)?…………. Court in County, day of , 20 Yes No 3 leg raising left Lumbar right lateral flexion (25°) f. Maximum straight leg raising left………………………………….. g. Total motion at midsacrum (1b + 2b)……………………………… (Attorney must sign h. Maximum midsacral motion………………………………………. above and type name below) i. Tightest SLR equal to or within 10° of maximum midsacral motion (3h)?.. Yes No j. Therefore, lumbar flexion is valid………………………………………… Yes No a. Degrees of right lateral flexion at T12…………………………….. Attorney(s) for b. Degrees of right lateral midsacral flexion………………………... c. Right lateral flexion angle (a minus b)…………………………….. d. Are measurements within +/- 10% or 5° (whichever is greater)?…………. Yes No Lumbar left lateral flexion (25°) e. Maximum lumbar right lateral flexion angle…………………….... Office and P.O. Address a. Degrees of left lateral flexion at T12………………………………. b. Degrees of left lateral midsacral flexion…………………………. c. Left lateral flexion angle (a minus b)……………………………… Telephone No.: d. Are measurements within +/- 10% or 5° (whichever is greater)?…………. Yes Straight leg Raising validity check 4 5 No Facsimile No.: e. Maximum lumbar left lateral flexion angle………………………... 440-2278 (3/00/DCBS/WCD/WEB) E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com