Motor Activity Log Lower Extremities
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1Motor Activity Log – Lower Extremities
Patient Name:
Date:
Injury:
Surgery:
Surgery Date:
Doctor Name:
Frequency
How Well Used
Activities
Amount of Pain
(None, Little,
(Full, Moderate,
Some, A Lot)
No Range)
1.
Sitting
2.
Standing
3.
Lying Down
4.
Walking with Crutches
5.
Walking without Crutches
6.
Swimming
7.
Climbing Stairs
8.
Driving
9.
Running
10.
Biking
11.
Jumping
Exercise:
12.
Exercise:
13.
Exercise:
14.
Exercise:
15.
Additional Comments
Comments:
Goals:
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Parent category: Miscellaneous