Spinal (Lumbar) Range Of Motion {2278L}

SPINAL (LUMBAR) RANGE OF MOTION. This form is used by health care providers to document and evaluate a worker’s lumbar spine mobility following a work-related injury. This form captures precise measurements of the spine's active range of motion using a single fluid-filled inclinometer, as outlined in Bulletin No. 239 issued by the Oregon Workers’ Compensation Division. It includes detailed fields for assessing lumbar flexion, extension, right and left lateral flexion, and passive straight-leg raising on both sides. Each section requires the provider to record at least three measurements and determine whether they fall within accepted variance limits. The form also includes a validity check for the straight-leg raising test to ensure the reliability of the lumbar flexion data. This completed form must be submitted with the physician’s report to support the worker’s compensation claim and provide a standardized reference for evaluating spinal function. www.FormsWorkflow.com