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Upper
Extremities / Routine Measurements Chart |
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NAME: |
Exam Date: |
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Injured
Extremity: |
Dominant
Hand: |
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Musculature/Measurements
(Comments on Report) |
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Circumferences (In Inches)Æ |
Upper Arms/Shoulders/Biceps / |
Forearms / |
Wrists / |
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Hands /Fingers: Thenar / Hypothenar/Intrinsic: |
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Motions: Report As Fraction (Injured/Uninjured)
In Degrees Of Active Motion. All Joints Of An Injured Extremity Must
Be Examined. 1 |
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Shoulder: 7.3 Rating based on Average of Abduction &
Forward Flexion. |
Abduction: ________________ |
Forearm Rotation: Disability 7.6 Determine the % loss of normal
range. (Schedule
Pg 2-8) |
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Extension: _____________ |
Forward Flexion: ________________ |
Pronation: / |
Supination: /_ |
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Internal Rotation:
_____________ |
Adduction: ________________ |
WRIST: Disability 7.7 Rating is Based on all
motions, with Dorsal and Palmar Flexion given twice the value of radial and
ulnar deviation. (Note 21 on Page 2-8 of The Schedule.) |
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External Rotation: ________________ |
Dorsal Flexion Palmar
Flexion |
/ / |
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ELBOW: Disability 7.5 Determine
loss of motion by dividing the number of degrees lost for one or both
flexion/extension. |
Radial
Deviation Ulnar
Deviation |
/ / |
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Flexion: _____/____Extension: ____/____
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Head Of
Radius: Intact:
_____ Partial Amputation: ______ Removed_____ (Schedule
Page 2-8.) |
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Report Motions As A Fraction:
Injured/Uninjured Note
Amputation Level By A Vertical Line Through The Joint/Phalanx Involved. If amputation is between joints, enter the
location between phalanx: i.e., proximal 1/2, proximal 1/3, distal 1/2. Written Examples: “Amputation distal 1/3 of the middle joint of the
ring finger” / “At proximal joint” /
“Proximal to the middle joint.” |
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Thumb: Abduction:
________/________ / (ADD.
Tip misses head of 5th MC. (Inches) ______________ |
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Digit |
Proximal Joint |
Middle Joint |
Distal Joint |
Fingertip Misses Mid-Palm
(In Inches) |
Amputation Level |
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Thumb Extension Flexion |
/ / |
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/ / |
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Index Extension |
/ |
/ |
/ |
/ |
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Middle Extension |
/ |
/ |
/ |
/ |
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Ring Extension |
/ |
/ |
/ |
/ |
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Little Extension |
/ |
/ |
/ |
/ |
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Grip
Dynamometer Readings: Maximum Effort:
___YES/____NO * Comments on Report. Injured / Uninjured ______/______ ______/______ ______/______ If Bilateral Injury- Estimated Percentages Of
Loss Are: _______% / _______% |
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Measurements Not Shown Will Be Considered Normal
Evaluation of Industrial Disability (Packard
Thurber, MD)- 8 CCR 46/9725:
Physician must report measurable physical elements of disability
in accordance with the standard method as described in the book. In the case of a bilateral
disability, state estimated normal as ABD, 140/160 (EN 180). Pages 11, 62, 63
of "Evaluation of Industrial Disability.” |
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