Shoulder Range of Motion Assessment Chart

Shoulder Range of Motion Chart
Patient information
Name:
Gender:
Flexion
Age:
Date:
Extension
External rotation
Internal rotation
Medial rotation
Horizontal adduction
Adduction
Abduction
Flexion
Left:
degrees
Right:
degrees
Is there pain on any side?
Yes
No
Is the movement smooth, controlled, and done with enough power?
Yes
No
If no, please elaborate:
Remarks:
Extension
Left:
degrees
Right:
Is there pain on any side?
Is the movement smooth, controlled, and done with enough power?
If no, please elaborate:
Remarks:
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degrees
Yes
Yes
No
No
Abduction
Left:
degrees
Right:
degrees
Is there pain on any side?
Yes
No
Is the movement smooth, controlled, and done with enough power?
Yes
No
Is there pain on any side?
Yes
No
Is the movement smooth, controlled, and done with enough power?
Yes
No
Is there pain on any side?
Yes
No
Is the movement smooth, controlled, and done with enough power?
Yes
No
Is there pain on any side?
Yes
No
Is the movement smooth, controlled, and done with enough power?
Yes
No
If no, please elaborate:
Remarks:
Adduction
Left:
degrees
Right:
degrees
If no, please elaborate:
Remarks:
External rotation
Left:
degrees
Right:
degrees
If no, please elaborate:
Remarks:
Internal rotation
Left:
degrees
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Right:
degrees
If no, please elaborate:
Remarks:
Medial rotation
Left:
degrees
Right:
degrees
Is there pain on any side?
Yes
No
Is the movement smooth, controlled, and done with enough power?
Yes
No
Is there pain on any side?
Yes
No
Is the movement smooth, controlled, and done with enough power?
Yes
No
If no, please elaborate:
Remarks:
Horizontal adduction
Left:
degrees
Right:
degrees
If no, please elaborate:
Remarks:
Additional comments and observations
Healthcare professional’s information
Name:
License number:
Signature:
Date:
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