Customer's practitioner describes scarring (location, description, type, length, width) for SGI's permanent impairment benefit assessment.
- Completed by
- Customer's practitioner
- Issued by
- SGI
- Format
- Sent for each case
- Language
- English
SGI Range of Motion Charts (Permanent Impairment)
SGI uses these joint-specific charts to measure range-of-motion loss when it assesses an injury claimant's permanent impairment benefit. It requests them about 10 months after the accident for the interim assessment and again at maximum medical improvement for the final one. Charts exist for the shoulder, elbow, wrist, thumb, fingers, hip, knee, ankle, big toe and temporomandibular joint.
Who completes it
A physiotherapist or occupational therapist chosen by the customer measures active range of motion and completes the chart, following the procedure set out on each form. SGI picks the charts from the customer's injuries and attaches them to its PI-ROM/Disfigurement request letter.
Submitting and payment
- How to submit it
- The physiotherapist or occupational therapist sends the completed chart to SGI with their invoice; SGI returns an incomplete chart to the therapist to finish.
- Who pays
- SGI pays the therapist's invoice for the range of motion form once it has checked that the form is fully completed.
Good to know
- Measure active range of motion with a goniometer or inclinometer, using the standardized positions and techniques in Appendix B of Division 1 of SGI's Injury Manual.
- SGI's manual says range of motion measurements must be done by a physiotherapist or occupational therapist, and the customer chooses which one.
- SGI's medical consultant uses the charts, along with hospital records and other reports, to rate permanent impairment; SGI's injury representative then decides the benefit.
- The charts are not published: SGI attaches the ones it needs to a letter titled PI-ROM/Disfigurement that it sends the customer.
Get the official form
Download the current version from the source each time; forms change without notice.
Range of Motion Charts
Fill it with Vero
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Frequently asked questions
Who can complete SGI range of motion charts?
A physiotherapist or an occupational therapist. SGI's Injury Manual says range of motion measurements must be completed by a PT or OT, and the customer chooses which one. Each chart sets out its own procedure, and active range of motion is measured with a goniometer or inclinometer using standardized positions and techniques.
When does SGI request range of motion measurements?
About 10 months after the accident, for the interim permanent impairment assessment and payment, and again when the customer reaches maximum medical improvement, for the final assessment. SGI contacts the customer to explain the process, then sends a written request with the charts that match the injured joints.
How is the therapist paid for SGI range of motion charts?
Send the completed chart to SGI together with your invoice. SGI's injury representative checks that the form is fully completed, contacts you and returns it if anything is missing, and processes payment once it is complete. The chart is then filed in the customer's medical file for the medical consultant's review.