Get the free G-250 (04-11). Form Approved OMB No. 3220-0038
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Do not skip any items unless directed to do so. Enter NA for not affected or UNK for unknown as appropriate. Attach a copy of any x-ray reports MRI reports CT scan reports etc. Is there a limitation of motion in the spine or any joints YES - Check this box then go to Item 5B and enter either the range of motion or an N for normal range of motion NO - Check this box then go to Item 6 RRB Form G-250 04-11 Destroy Prior Editions Normal Degrees CERVICAL SPINE Flexion Actual DORSOLUMBAR SPINE...
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