Activity/Rest Assessment Tool

Subjective (Reports)

Occupation:________________Able to participate in usual activities/hobbies:________________________
Leisure time/diversional activities:_________________

Ambulatory:_________________Gait (describe):____________________Activity level (sedentary to very active):______________Daily exercise (type):______________________

Changes in muscle mass/tone/strength:___________________________

History of problems/limitations imposed by condition (e.g., immobility, transfer difficulties, weakness,breathlessness):_________________________________________________________________

Feelings (e.g., exhaustion, restlessness, boredom, dissatisfaction):___________________________________________________

Developmental factors (e.g., delayed/age):_____________________________________________________________________________

Sleep:___________________Hours:_____________________Naps:___________________Aids:___________
Insomnia:________________Related to:_________________

Difficulty falling asleep:________________________Difficulty staying asleep:_________________________

Rested on awakening:______________________Excessive grogginess:______________________
Bedtime rituals:___________________________

Relaxation techniques:_____________________Sleeps on more than one pillow:___________________________________

Use of oxygen (type):____________________________When used:_________________________

Medications or herbals for/affecting sleep:_________________________________________

Objective (Exhibits)
Observed response to activity: Heart rate:___________Rhythm (reg/irreg):____________
Blood pressure:______________Respiratory rate:__________

Pulse oximetry:________________________________

Mental status (e.g., cognitive impairment, withdrawn/lethargic):_____________________________

Neuromuscular assessment: Muscle mass/tone:_________________________________________
Posture (e.g., normal, stooped, curved spine):____________________________________________

Tremors (location):__________________________ROM:_____________________________

Strength:_____________________________Deformity:_______________________________

Mobility aids (list):_____________________________________________________________