Name(s): Date:

Activity Analysis Form:

Occupation:
Area(s) of occupation for the client: Subcategory:
☐ Activities of daily living Explanation

☐ Instrumental activities of daily living

☐ Education
☐ Work
☐ Play
☐ Leisure
☐ Social participation

Objects and their properties required:

[Tools, supplies, equipment required to process the activity]

;
Space demands:
[Relating to the physical environment (size, arrangement, surface, lighting, temperature, noise,
humidity, ventilation)]

Social demands:
[Relating to the social environment and virtual and cultural context (rules of the game,
expectations of participants, sharing supplies, etc.)]
 2

Sequence and timing:

Body functions required:

Function None Minimally Greatly How is it used

Challenged Challenged
Specific mental Functions
Higher-level cognitive:
judgment, concept formation,
metacognition, executive
functions, praxis, cognitive
flexibility, insight
Attention: sustained attention
and concentration; selective,
divided, and shifting attention
Name(s): Date:

Memory: short-term, working,

and long-term memory

Perception: discrimination of
sensations–auditory, tactile,
visual, olfactory, gustatory,
ves- tibular, and proprioceptive

Thought: control and content

of thought, awareness of
reality, logical and coherent
thought

Sequencing complex move-

ment: regulating speed,
response, quality, and time
of motor production
Emotional: regulation and
range of emotion, appropri-
ateness of emotions
Experience of self and time:
appropriateness and range
of emotion, body image,
self-concept
Global Mental Functions
Consciousness: awareness and
alertness, clarity and continu-
ity of the wakeful state
Orientation: orientation to per-
son and self, place, time, and
others
Temperament and personal-
ity: extroversion,
introversion, agreeableness,
and conscien- tiousness;
emotional stabil- ity;
openness to experience; self-
expression; confidence;
motivation; self-control and
impulse control; appetite

Function None Minimally Greatly How it is used

Challenged Challenged
Global Mental Functions
Energy and drive: motivation,
impulse control, appetite
Sleep: physiological process
4

Sensory Functions
Visual: quality of vision,
visual acuity, visual
stability, visual field
Hearing: sound detection
and discrimination,
awareness of location and
distance of sounds
Vestibular: position, balance,
secure movement against
gravity
Taste: qualities of bitterness,
sweetness, sourness, and
saltiness
Smell: sensing odors and
smells
Proprioceptive: awareness of
body position and space
Touch: feeling of being
touched, touching various
textures
Pain: localized and general-
ized pain
Temperature and pressure:
thermal awareness, sense of
force applied to the skin
Neuromusculoskeletal and movement-related Functions
Joint mobility: joint range of
motion
Joint stability: structural integ-
rity of joints
Muscle Functions
Muscle power: strength

Muscle tone: degree of mus-

cle tension
Muscle endurance: sustaining
muscle contraction

Function None Minimally Greatly How it is used

Challenged Challenged
Movement Functions
Motor reflexes: involun-
tary reflexes–involuntary
contractions of muscles
automatically induced by
stretching
Name(s): Date:

Involuntary movement
reactions: postural, body
adjustment, and supporting
reactions
Control of voluntary move-
ment: eye-hand and eye-
foot coordination, bilateral
integration, crossing
midline, fine and gross
motor control, oculomotor
control
Gait patterns: movements
used to walk

Cardiovascular, hematological, immunological, and respiratory system Functions

Cardiovascular system:
blood pressure, heart rate
and rhythm
Hematological and immu-
nological systems

Respiratory system: rate,

rhythm, and depth of
respiration
Additional functions of the
cardiovascular and respi-
ratory systems: physical
endurance, stamina, aerobic
capacity
Voice and speech; digestive, metabolic, and endocrine systems; and genitourinary and reproductive systems
Functions
Voice and speech: rhythm
and fluency, alternative
vocalization functions
Digestive, metabolic, and
endocrine systems
Genitourinary and reproduc-
tive systems: urinary,
genital, and reproductive
functions
Skin and related structures Functions
Skin: protection and repair

Hair and nails

 6

Muscular analysis of movements required:

Muscle Not Used Minimally Challenged Greatly challenged Comments

Shoulder flexion
Shoulder extension
Shoulder abduction
Shoulder adduction
Shoulder internal
rotation
Shoulder external
rotation
Elbow flexion
Elbow extension
Wrist supination
Wrist pronation
Wrist flexion
Wrist extension
Thumb flexion
Thumb abduction
Finger flexion
Finger extension
Trunk flexion
Trunk extension
Trunk rotation
Lower extremities

Body structures required:

Category Body Structure Required? (Check if

yes)
Nervous system Frontal lobe
Temporal lobe
Parietal lobe
Occipital lobe
Midbrain
Diencephalon
Basal ganglia
Name(s): Date:

Cerebellum
Brainstem
Cranial nerves
Spinal cord
Spinal nerves
Meninges
Sympathetic nervous system
Parasympathetic nervous system
eyes, ears, and related Eyeball: Conjunctiva, cornea, iris, retina, lens, vitreous body
structures
Structures around eye: Lachrimal gland, eyelid, eyebrow, external
ocular muscles
Structure of external ear
Structure of middle ear: Tympanic membrane, eustachian canal,
ossicles
Structures of inner ear: Cochlea, vestibular labyrinth, semicircular
canals, internal auditory meatus
Voice and speech Structures of the nose: External nose, nasal septum, nasal fossae
structures
Structure of the mouth: Teeth, gums, hard palate, soft palate, tongue,
lips
Structure of pharynx: Nasal pharynx and oral pharynx
Structure of larynx: Vocal folds
cardiovascular system Heart: Atria, ventricles
Arteries
Veins
Capillaries

Category Body Structure Required? (Check

if yes)
immunological system Lymphatic vessels

Lymphatic nodes
Thymus
Spleen
Bone marrow
respiratory system Trachea

Lungs: Bronchial tree, alveoli

Thoracic cage
Muscles of respiration: Intercostal muscles, diaphragm
digestive, metabolic, and Salivary glands
endocrine systems
Esophagus
8

Stomach
Intestines: Small and large
Pancreas
Liver
Gall bladder and ducts
Endocrine glands: Pituitary, thyroid, parathyroid, adrenal
genitourinary and repro- Urinary system: Kidneys, ureters, bladder, urethra
ductive systems
Structure of pelvic floor
Structure of reproductive system: Ovaries, uterus, breast and nip-
ple, vagina and external genitalia, testes, penis, prostate
structures related to Bones of cranium
movement
Bones of face
Bones of neck region
Joints of head and neck
Bones of shoulder region
Joints of shoulder region
Muscles of shoulder region
Bones of upper arm
Elbow joint
Muscles of upper arm
Ligaments and fascia of upper arm
Bones of forearm
Wrist joint
Muscles of forearm

Category Body structure Required?

(Check if yes)
structures related Ligaments and fascia of forearm
to movement
Bones of hand
Joints of hand and fingers
Muscles of hand
Ligaments and fascia of hand
Bones of pelvic region
Joints of pelvic region
Muscles of pelvic region
Ligaments and fascia of pelvic region
Bones of thigh
Hip joint
Muscles of thigh
Name(s): Date:

Ligaments and fascia of thigh

Bones of lower leg
Knee joint
Muscles of lower leg
Ligaments and fascia of lower leg
Bones of ankle and foot
Ankle, foot, and toe joints
Muscle of ankle and foot
Ligaments of fascia of ankle and foot
Cervical vertebral column
Lumbar vertebral column
Sacral vertebral column
Muscles of trunk
Ligaments and fascia of trunk
skin and Areas of skin: Head, neck, shoulder, upper extremity, pelvic region,
related lower extremities, trunk, and back
structures
Structure of skin glands: Sweat and sebaceous
Structure of nails: Fingernails and toenails
Structure of hair

Performance skills required:

Skill None Low Medium High Example of how skill is used . . .

motor skills
Aligns
Stabilizes
Positions
Reaches
Bends
Grips
Manipulates
Coordinates
Moves
Lifts
Walks
Transports
Calibrates
Flows
Endures
Paces
Process skills
Paces
10

Attends
Heeds
Chooses
Uses
Handles
Inquires
Initiates
Continues

Sequences

Terminates
Searches/locates
Gathers
Organizes
Restores

Skill None Low Medium High Example of how skill is used

Process skill
Navigates
Notices/responds
Adjusts
Accommodates
Benefits
Social interaction skills
Approaches/ starts
Concludes/disengages
Produces speech
Gesticulates
Speaks fluently
Turns toward
Looks
Places self
Touches

Regulates

Questions
Replies
Discloses
Expresses emotion
Name(s): Date:

Disagrees
Thanks

Transitions
Times response
Times duration

Takes turns
Matches language
Clarifies

Acknowledges and
encourages
Empathizes
Heeds
Accommodates
Benefits