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Diagnosis and Impairments
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Affected Body Parts
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Shoulder
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Range of Motion (Left/Right)
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Flexion
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UEI (%)
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Extension
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UEI (%)
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Adduction
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UEI (%)
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Abduction
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UEI (%)
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External rotation at 90
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UEI (%)
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Internal rotation at 90
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UEI (%)
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Surgical Procedure(s)
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Surgical Procedure(s)
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UEI (%)
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Elbow
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Range of Motion (Left/Right)
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Flexion
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UEI (%)
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Extension
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UEI (%)
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Pronation
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UEI (%)
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Supination
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UEI (%)
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Grip Strength
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Average Grip Strength (Left)
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Average Grip Strength (Right)
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Strength Loss Index
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UEI (%)
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Surgical Procedure(s)
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Surgical Procedure(s)
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UEI (%)
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Knee
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Range of Motion (Left/Right)
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Extension
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LEI (%)
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Flexion
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LEI (%)
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Atrophy (cm)
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Quadriceps Atrophy
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LEI (%)
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Calf Atrophy
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LEI (%)
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Muscle Weakness (0-5)
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Flexion
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LEI (%)
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Extension
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LEI (%)
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Surgical Procedure(s)
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Surgical Procedure(s)
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LEI (%)
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X-Ray Cartilage Intervals
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X-ray Cartilage Intervals
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LEI (%)
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Ankle
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Range of Motion (Left/Right)
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Dorsiflexion
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LEI (%)
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Plantarflexion
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LEI (%)
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Inversion
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LEI (%)
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Eversion
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LEI (%)
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Surgical Procedure(s)
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Surgical Procedure(s)
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LEI (%)
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Additional Comments
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Cervical Spine
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Range of Motion
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Flexion
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WPI (%)
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Extension
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WPI (%)
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Right Lateral Bend
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WPI (%)
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Left Lateral Bend
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WPI (%)
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Right Rotation
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WPI (%)
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Left Rotation
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WPI (%)
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Surgical Procedure(s)
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Surgical Procedure(s)
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UEI (%)
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Lumbar Spine
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Range of Motion
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Flexion
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WPI (%)
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Extension
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WPI (%)
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Right Lateral Bend
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WPI (%)
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Left Lateral Bend
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WPI (%)
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Surgical Procedure(s)
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Surgical Procedure(s)
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LEI (%)
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Total Impairment Values
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Upper Extremity Impairment (%)
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Lower Extremity Impairment (%)
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Whole Person Impairment (%)
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