The following self assessment questionnaire is freely inspired by the OSA model, it aims to stimulate reflection on actions performed routinely throughout the day through the use of the upper limbs.
This will help you and us better understand what are your needs and your priorities.
All collected data is strictly confidential and will be used solely for the purpose of assessing your needs.

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Detailed Upper Limb-Focused Daily Activity Self Assessment Questionnaire

Name

First

Last

Diagnosis (EB, upper limb amputation, etc.)

Reflect on a typical day from morning until night.
For each activity that involves the use of your upper limbs, rate your ability to perform it and its importance to you.

Layout

Morning Routine - Easiness

	Lot of problems	Some difficulty	Well	Extremely well
Turning off the alarm clock.	Lot of problemsTurning off the alarm clock. Lot of problems	Some difficultyTurning off the alarm clock. Some difficulty	WellTurning off the alarm clock. Well	Extremely wellTurning off the alarm clock. Extremely well
Opening and closing curtains or blinds.	Lot of problemsOpening and closing curtains or blinds. Lot of problems	Some difficultyOpening and closing curtains or blinds. Some difficulty	WellOpening and closing curtains or blinds. Well	Extremely wellOpening and closing curtains or blinds. Extremely well
Dressing (including fastening buttons, zipping zippers).	Lot of problemsDressing (including fastening buttons, zipping zippers). Lot of problems	Some difficultyDressing (including fastening buttons, zipping zippers). Some difficulty	WellDressing (including fastening buttons, zipping zippers). Well	Extremely wellDressing (including fastening buttons, zipping zippers). Extremely well
Personal hygiene (brushing teeth, combing hair, applying makeup/shaving).	Lot of problemsPersonal hygiene (brushing teeth, combing hair, applying makeup/shaving). Lot of problems	Some difficultyPersonal hygiene (brushing teeth, combing hair, applying makeup/shaving). Some difficulty	WellPersonal hygiene (brushing teeth, combing hair, applying makeup/shaving). Well	Extremely wellPersonal hygiene (brushing teeth, combing hair, applying makeup/shaving). Extremely well
Preparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread).	Lot of problemsPreparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread). Lot of problems	Some difficultyPreparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread). Some difficulty	WellPreparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread). Well	Extremely wellPreparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread). Extremely well

Work/Daytime Activities - Easiness

	Lot of problems	Some difficulty	Well	Extremely well
Writing or typing.	Lot of problemsWriting or typing. Lot of problems	Some difficultyWriting or typing. Some difficulty	WellWriting or typing. Well	Extremely wellWriting or typing. Extremely well
Using a phone or computer.	Lot of problemsUsing a phone or computer. Lot of problems	Some difficultyUsing a phone or computer. Some difficulty	WellUsing a phone or computer. Well	Extremely wellUsing a phone or computer. Extremely well
Opening doors or handling keys.	Lot of problemsOpening doors or handling keys. Lot of problems	Some difficultyOpening doors or handling keys. Some difficulty	WellOpening doors or handling keys. Well	Extremely wellOpening doors or handling keys. Extremely well
Preparing meals or snacks.	Lot of problemsPreparing meals or snacks. Lot of problems	Some difficultyPreparing meals or snacks. Some difficulty	WellPreparing meals or snacks. Well	Extremely wellPreparing meals or snacks. Extremely well
Household chores (cleaning surfaces, doing laundry).	Lot of problemsHousehold chores (cleaning surfaces, doing laundry). Lot of problems	Some difficultyHousehold chores (cleaning surfaces, doing laundry). Some difficulty	WellHousehold chores (cleaning surfaces, doing laundry). Well	Extremely wellHousehold chores (cleaning surfaces, doing laundry). Extremely well

Evening Activities - Easiness

	Lot of problems	Some difficulty	Well	Extremely well
Preparing dinner (cutting, stirring, opening containers).	Lot of problemsPreparing dinner (cutting, stirring, opening containers). Lot of problems	Some difficultyPreparing dinner (cutting, stirring, opening containers). Some difficulty	WellPreparing dinner (cutting, stirring, opening containers). Well	Extremely wellPreparing dinner (cutting, stirring, opening containers). Extremely well
Eating (holding utensils, cutting food).	Lot of problemsEating (holding utensils, cutting food). Lot of problems	Some difficultyEating (holding utensils, cutting food). Some difficulty	WellEating (holding utensils, cutting food). Well	Extremely wellEating (holding utensils, cutting food). Extremely well
Personal care activities (washing face, brushing teeth).	Lot of problemsPersonal care activities (washing face, brushing teeth). Lot of problems	Some difficultyPersonal care activities (washing face, brushing teeth). Some difficulty	WellPersonal care activities (washing face, brushing teeth). Well	Extremely wellPersonal care activities (washing face, brushing teeth). Extremely well
Changing clothes or getting ready for bed.	Lot of problemsChanging clothes or getting ready for bed. Lot of problems	Some difficultyChanging clothes or getting ready for bed. Some difficulty	WellChanging clothes or getting ready for bed. Well	Extremely wellChanging clothes or getting ready for bed. Extremely well
Turning off lights or setting alarms.	Lot of problemsTurning off lights or setting alarms. Lot of problems	Some difficultyTurning off lights or setting alarms. Some difficulty	WellTurning off lights or setting alarms. Well	Extremely wellTurning off lights or setting alarms. Extremely well

Health, Recreational and Social Activities - Easiness

	Lot of problems	Some difficulty	Well	Extremely well
Engaging in hobbies (crafts, playing an instrument, gardening).	Lot of problemsEngaging in hobbies (crafts, playing an instrument, gardening). Lot of problems	Some difficultyEngaging in hobbies (crafts, playing an instrument, gardening). Some difficulty	WellEngaging in hobbies (crafts, playing an instrument, gardening). Well	Extremely wellEngaging in hobbies (crafts, playing an instrument, gardening). Extremely well
Using electronic devices for leisure (e-readers, gaming consoles).	Lot of problemsUsing electronic devices for leisure (e-readers, gaming consoles). Lot of problems	Some difficultyUsing electronic devices for leisure (e-readers, gaming consoles). Some difficulty	WellUsing electronic devices for leisure (e-readers, gaming consoles). Well	Extremely wellUsing electronic devices for leisure (e-readers, gaming consoles). Extremely well
Applying or removing bandages, braces, or prosthetic devices.	Lot of problemsApplying or removing bandages, braces, or prosthetic devices. Lot of problems	Some difficultyApplying or removing bandages, braces, or prosthetic devices. Some difficulty	WellApplying or removing bandages, braces, or prosthetic devices. Well	Extremely wellApplying or removing bandages, braces, or prosthetic devices. Extremely well
Taking medications (opening bottles, using syringes or inhalers).	Lot of problemsTaking medications (opening bottles, using syringes or inhalers). Lot of problems	Some difficultyTaking medications (opening bottles, using syringes or inhalers). Some difficulty	WellTaking medications (opening bottles, using syringes or inhalers). Well	Extremely wellTaking medications (opening bottles, using syringes or inhalers). Extremely well
Shopping (selecting items, carrying bags, paying for purchases).	Lot of problemsShopping (selecting items, carrying bags, paying for purchases). Lot of problems	Some difficultyShopping (selecting items, carrying bags, paying for purchases). Some difficulty	WellShopping (selecting items, carrying bags, paying for purchases). Well	Extremely wellShopping (selecting items, carrying bags, paying for purchases). Extremely well
Handling mail or packages (opening envelopes, unpacking boxes).	Lot of problemsHandling mail or packages (opening envelopes, unpacking boxes). Lot of problems	Some difficultyHandling mail or packages (opening envelopes, unpacking boxes). Some difficulty	WellHandling mail or packages (opening envelopes, unpacking boxes). Well	Extremely wellHandling mail or packages (opening envelopes, unpacking boxes). Extremely well
Driving or using public transport controls (if applicable).	Lot of problemsDriving or using public transport controls (if applicable). Lot of problems	Some difficultyDriving or using public transport controls (if applicable). Some difficulty	WellDriving or using public transport controls (if applicable). Well	Extremely wellDriving or using public transport controls (if applicable). Extremely well

Morning Routine - Importance

	Not so important	Important	More important	Most important
Turning off the alarm clock.	Not so importantTurning off the alarm clock. Not so important	ImportantTurning off the alarm clock. Important	More importantTurning off the alarm clock. More important	Most importantTurning off the alarm clock. Most important
Opening and closing curtains or blinds.	Not so importantOpening and closing curtains or blinds. Not so important	ImportantOpening and closing curtains or blinds. Important	More importantOpening and closing curtains or blinds. More important	Most importantOpening and closing curtains or blinds. Most important
Dressing (including fastening buttons, zipping zippers).	Not so importantDressing (including fastening buttons, zipping zippers). Not so important	ImportantDressing (including fastening buttons, zipping zippers). Important	More importantDressing (including fastening buttons, zipping zippers). More important	Most importantDressing (including fastening buttons, zipping zippers). Most important
Personal hygiene (brushing teeth, combing hair, applying makeup/shaving).	Not so importantPersonal hygiene (brushing teeth, combing hair, applying makeup/shaving). Not so important	ImportantPersonal hygiene (brushing teeth, combing hair, applying makeup/shaving). Important	More importantPersonal hygiene (brushing teeth, combing hair, applying makeup/shaving). More important	Most importantPersonal hygiene (brushing teeth, combing hair, applying makeup/shaving). Most important
Preparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread).	Not so importantPreparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread). Not so important	ImportantPreparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread). Important	More importantPreparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread). More important	Most importantPreparing breakfast (opening bottles, pouring coffee/tea, spreading butter/jam, cutting bread). Most important

Work/Daytime Activities - Importance

	Not so important	Important	More important	Most important
Writing or typing.	Not so importantWriting or typing. Not so important	ImportantWriting or typing. Important	More importantWriting or typing. More important	Most importantWriting or typing. Most important
Using a phone or computer.	Not so importantUsing a phone or computer. Not so important	ImportantUsing a phone or computer. Important	More importantUsing a phone or computer. More important	Most importantUsing a phone or computer. Most important
Opening doors or handling keys.	Not so importantOpening doors or handling keys. Not so important	ImportantOpening doors or handling keys. Important	More importantOpening doors or handling keys. More important	Most importantOpening doors or handling keys. Most important
Preparing meals or snacks.	Not so importantPreparing meals or snacks. Not so important	ImportantPreparing meals or snacks. Important	More importantPreparing meals or snacks. More important	Most importantPreparing meals or snacks. Most important
Household chores (cleaning surfaces, doing laundry).	Not so importantHousehold chores (cleaning surfaces, doing laundry). Not so important	ImportantHousehold chores (cleaning surfaces, doing laundry). Important	More importantHousehold chores (cleaning surfaces, doing laundry). More important	Most importantHousehold chores (cleaning surfaces, doing laundry). Most important

Evening Activities - Importance

	Not so important	Important	More important	Most important
Preparing dinner (cutting, stirring, opening containers).	Not so importantPreparing dinner (cutting, stirring, opening containers). Not so important	ImportantPreparing dinner (cutting, stirring, opening containers). Important	More importantPreparing dinner (cutting, stirring, opening containers). More important	Most importantPreparing dinner (cutting, stirring, opening containers). Most important
Eating (holding utensils, cutting food).	Not so importantEating (holding utensils, cutting food). Not so important	ImportantEating (holding utensils, cutting food). Important	More importantEating (holding utensils, cutting food). More important	Most importantEating (holding utensils, cutting food). Most important
Personal care activities (washing face, brushing teeth).	Not so importantPersonal care activities (washing face, brushing teeth). Not so important	ImportantPersonal care activities (washing face, brushing teeth). Important	More importantPersonal care activities (washing face, brushing teeth). More important	Most importantPersonal care activities (washing face, brushing teeth). Most important
Changing clothes or getting ready for bed.	Not so importantChanging clothes or getting ready for bed. Not so important	ImportantChanging clothes or getting ready for bed. Important	More importantChanging clothes or getting ready for bed. More important	Most importantChanging clothes or getting ready for bed. Most important
Turning off lights or setting alarms.	Not so importantTurning off lights or setting alarms. Not so important	ImportantTurning off lights or setting alarms. Important	More importantTurning off lights or setting alarms. More important	Most importantTurning off lights or setting alarms. Most important

Health, Recreational and Social Activities - Importance

	Not so important	Important	More important	Most important
Engaging in hobbies (crafts, playing an instrument, gardening).	Not so importantEngaging in hobbies (crafts, playing an instrument, gardening). Not so important	ImportantEngaging in hobbies (crafts, playing an instrument, gardening). Important	More importantEngaging in hobbies (crafts, playing an instrument, gardening). More important	Most importantEngaging in hobbies (crafts, playing an instrument, gardening). Most important
Using electronic devices for leisure (e-readers, gaming consoles).	Not so importantUsing electronic devices for leisure (e-readers, gaming consoles). Not so important	ImportantUsing electronic devices for leisure (e-readers, gaming consoles). Important	More importantUsing electronic devices for leisure (e-readers, gaming consoles). More important	Most importantUsing electronic devices for leisure (e-readers, gaming consoles). Most important
Applying or removing bandages, braces, or prosthetic devices.	Not so importantApplying or removing bandages, braces, or prosthetic devices. Not so important	ImportantApplying or removing bandages, braces, or prosthetic devices. Important	More importantApplying or removing bandages, braces, or prosthetic devices. More important	Most importantApplying or removing bandages, braces, or prosthetic devices. Most important
Taking medications (opening bottles, using syringes or inhalers).	Not so importantTaking medications (opening bottles, using syringes or inhalers). Not so important	ImportantTaking medications (opening bottles, using syringes or inhalers). Important	More importantTaking medications (opening bottles, using syringes or inhalers). More important	Most importantTaking medications (opening bottles, using syringes or inhalers). Most important
Shopping (selecting items, carrying bags, paying for purchases).	Not so importantShopping (selecting items, carrying bags, paying for purchases). Not so important	ImportantShopping (selecting items, carrying bags, paying for purchases). Important	More importantShopping (selecting items, carrying bags, paying for purchases). More important	Most importantShopping (selecting items, carrying bags, paying for purchases). Most important
Handling mail or packages (opening envelopes, unpacking boxes).	Not so importantHandling mail or packages (opening envelopes, unpacking boxes). Not so important	ImportantHandling mail or packages (opening envelopes, unpacking boxes). Important	More importantHandling mail or packages (opening envelopes, unpacking boxes). More important	Most importantHandling mail or packages (opening envelopes, unpacking boxes). Most important
Driving or using public transport controls (if applicable).	Not so importantDriving or using public transport controls (if applicable). Not so important	ImportantDriving or using public transport controls (if applicable). Important	More importantDriving or using public transport controls (if applicable). More important	Most importantDriving or using public transport controls (if applicable). Most important

What tasks do you find most challenging in your daily routine? Are there specific activities where you would like to improve your ability or independence? What features or support in prosthetics or tools would assist you in these tasks?

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Guide

Detailed Upper Limb-Focused Daily Activity Self Assessment Questionnaire

Reflect on a typical day from morning until night.
For each activity that involves the use of your upper limbs, rate your ability to perform it and its importance to you.

Legal & stuff

Detailed Upper Limb-Focused Daily Activity Self Assessment Questionnaire

Reflect on a typical day from morning until night. For each activity that involves the use of your upper limbs, rate your ability to perform it and its importance to you.

Legal & stuff

Reflect on a typical day from morning until night.
For each activity that involves the use of your upper limbs, rate your ability to perform it and its importance to you.