Name:____________________ Ref. Dr:___________________ Date: ________
Age: _______ Gender: M / F Dominance: R / L Injured Hand: R / L

RANGE OF MOTION TESTING:
CERVICAL ROM (Circle your Approved Choice)
Flexion:	_____  _____  _____  45

Extension:	_____  _____  _____  45

Lateral Right:	_____  _____  _____  45

Lateral Left:	_____  _____  _____  45

Rotation Right:	_____  _____  _____  80

Rotation left:	_____  _____  _____  80
THORACOLUMBAR ROM (Circle your Approved Choice)
Flexion:	_____  _____  _____  90

Extension:	_____  _____  _____  30

Lateral Right:	_____  _____  _____  30

Lateral Left:	_____  _____  _____  30

Rotation Right:	_____  _____  _____  30

Rotation left:	_____  _____  _____  30
COMMENTS:
COMPARATIVE MUSCLE TESTING:
CERVICAL CMT
Flexion:  	_____  _____

Extension:	_____  _____

Lateral Right:	_____  _____

Lateral Left:	_____  _____

Rotation Right:	_____  _____

Rotation Left:  _____  _____
LUMBAR CMT
Flexion:  	_____  _____

Extension:	_____  _____
KNEE CMT
RIGHT
Flexion:  	_____  _____

Extension:	_____  _____
LEFT
Flexion:  	_____  _____

Extension:	_____  _____

GRIP TEST
Grip Right:	_____  _____

Grip Left:	_____  _____
PINCH TEST
Pinch Right:	_____  _____

Pinch Left:	_____  _____
N.I.O.S.H. 6 LIFT TASK:
Arm:	   _____  _____

Torso:	   _____  _____

Leg:	   _____  _____

High Far:  _____  _____

Floor:	   _____  _____

High Near: _____  _____