Range of Motion and Deformity/Deviation - Amputation and Sensation of the Upper Extremity - Oregon 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the worker’s name, date of injury (DOI), and WCD number at the top of the form.
3. In the 'Range of Motion' section, report active range of motion for each joint. Use the provided degrees as a reference for normal values. Fill in both right and left joints accordingly.
4. Identify any rotational deformities or lateral deviations for each finger on both hands. Mark 'yes' or 'no' as applicable.
5. Proceed to the 'Amputation and Sensation' section. Indicate any amputations by checking the appropriate boxes and marking on illustrations where necessary.
6. For sensation grading, mark and grade palmar surface sensation according to the specified criteria.
7. Finally, have the examining physician print their name, title, sign, and date the examination at the bottom of the form.

Start using our platform today to easily complete your forms online for free!