Spinal (Thoracic) 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 Thoracic Flexion (50°) a. T12 angle compared to T1 (flexed)............................................. 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............................................... a. Degrees of right rotation at T1.................................................. b. Degrees of right rotation at T12................................................ c. Thoracic right rotation angle (a minus b)...................................... d. Are measurements within +/- 10% or 5° (whichever is greater)?.................. e. Maximum thoracic right rotation angle........................................ a. Degrees of left rotation at T1.................................................... b. Degrees of left rotation at T12.................................................. c. Thoracic left rotation angle (a minus b)....................................... d. Are measurements within +/- 10% or 5° (whichever is greater)?.................. e. Maximum thoracic left rotation angle.......................................... Yes No Thoracic right rotation 2 (30°) Yes No Thoracic left rotation 3 (30°) Yes No Examining physician name and title (print or type): Signature: 440-2278T(6/10/DCBS/WCD/WEB) Date of examination: American LegalNet, Inc. www.FormsWorkFlow.com