Motor Activity Log Upper Extremities
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1Motor Activity Log – Upper Extremities
Patient Name:
Date:
Injury:
Surgery:
Surgery Date:
Doctor Name:
Amount Used
How Well Used
Activities
Comments
(None, Little, Some,
(Full, Moderate,
A Lot)
No Range)
1.
Turn off/on a light switches
2.
Open a can/twist open a bottle
3.
Open a drawer
4.
Pick up/dial a phone and text
5.
Button a shirt
6.
Put on pants
7.
Put on shoes
8.
Unlock and open a door with a doorknob
9.
Change the TV channel
10.
Type on a computer keyboard
11.
Use the toilet
Brush teeth
12.
Wash hands
13.
Open the fridge
14.
Use a knife and fork
15.
16.
Wash/dry dishes
Additional Comments
Comments:
Goals:
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Parent category: Miscellaneous