MotionPlus Patient Work Week One

Welcome to your first week of the MotionPlus program!

CLICK HERE to download the week one reading
Complete the questions under week one in your Activity Book
Provide the information requested in the form below

Patient Information - Step 1 of 7

Today's Date *

Name *

First

Last

Email *

Date of Birth *

My weight today is (kg)... *

My height is (cm)... *

My Patient Partner is... *

My surgeon is... *

What type of pain do you have? *

Knee
Hip

What side is your pain on? *

Left
Right
Both

Please indicate which statement best describes your own health state today

Mobility *

I have no problems in walking about
I have slight problems in walking about
I have moderate problems in walking about
I have severe problems in walking about
I am unable to walk about

Self Care *

I have no problems in washing or dressing myself
I have slight problems in washing or dressing myself
I have moderate problems in washing or dressing myself
I have severe problems in washing or dressing myself
I am unable to walk about wash or dress myself

Usual Activities (eg. work, study, housework, family or leisure activities) *

I have no problems in doing my usual activities
I have slight problems in doing my usual activities
I have moderate problems in doing my usual activities
I have severe problems in doing my usual activities
I am unable to do my usual activities

Pain / Discomfort *

I have no pain or discomfort
I have slight pain or discomfort
I have moderate pain or discomfort
I have severe pain or discomfort
I have extreme pain or discomfort

Anxiety / Depression *

I am not anxious or depressed
I am slightly anxious or depressed
I am moderatly anxious or depressed
I am severely anxious or depressed
I am extremely anxious or depressed

We would like you to indicate how good or bad your own health is today, in your opinion. *

0 (Worst imaginable)
10
20
30
40
50
60
70
80
90
100 (Best imaginable)

Overall Health - If you are unsure how to answer a question, please give the best answer you can

In general, would you say your health is... *

Excellent
Very Good
Good
Fair
Poor

The following questions are about activities you might do during a typical day.

Does your health now limit you from performing MODERATE ACTIVITIES, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? *

Yes, limited a lot
Yes, limited a little
No, not limited at all

Does your health now limit you in climbing SEVERAL flights of stairs? *

Yes, limited a lot
Yes, limited a little
No, not limited at all

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

Over the last 4 weeks, have you ACCOMPLISHED LESS than you would like due to your physical health? *

All of the time
Most of the time
Some of the time
Only a little of the time
None of the time

Over the last 4 weeks were you limited in the KIND of work or other activities you wanted to do, due to your physical health? *

All of the time
Most of the time
Some of the time
Only a little of the time
None of the time

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

Over the last 4 weeks, ACCOMPLISHED LESS than you would like due to emotional problems (such as feeling anxious or depressed)? *

All of the time
Most of the time
Some of the time
Only a little of the time
None of the time

Over the last 4 weeks, how often did you choose NOT TO DO ACTIVITIES or WORK as carefully as usual due to emotional problems (such as feeling anxious or depressed)? *

All of the time
Most of the time
Some of the time
Only a little of the time
None of the time

Over the last four weeks, how much did PAIN interfere with your house work and work outside the home? *

Not at all
A little bit
Moderately
Quite a bit
Extremely

These questions are about how you have been feeling during the past 4 weeks. How much of the time during the past 4 weeks?

Over the last four weeks, how often have you felt calm and peaceful? *

All of the time
Most of the time
Some of the time
Only a little of the time
None of the time

Over the last four weeks, how often have you had a lot of energy? *

All of the time
Most of the time
Some of the time
Only a little of the time
None of the time

Over the last four weeks, how often have you felt downhearted and depressed? *

All of the time
Most of the time
Some of the time
Only a little of the time
None of the time

Over the last four weeks, how much of the time has your health (physical and emotional) interfered with you spending time with friends and family? *

All of the time
Most of the time
Some of the time
Only a little of the time
None of the time

Below are some statements that people sometimes make when they talk about their health. Please indicate how much you agree or disagree with each statement as it applies to you personally by circling your answer. Your answers should be what is true for you and not just what others want you to say. If the statement does not apply to you, please tick N/A

When all is said and done, I am the person who is responsible for taking care of my health *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

Taking an active role in my own health care is the most important thing that affects my health *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

I know what each of my prescribed medications do *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

I am confident that I can tell whether I need to go to the doctor or whether I can take care of a health problem myself *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

I am confident that I can tell a doctor my concerns , even when he or she does not ask *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

I am confident that I can follow through on medical treatments I may need to do at home *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

I know how to prevent problems with my health *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

I am confident that I can figure out solutions when new problems arise with my health *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

I am confident that I can maintain lifestyle changes, like eating right and exercising, even during times of stress *

Disagree Strongly
Disagree
Agree
Agree Strongly
N/A

How would you rate your pain on a scale of 0 to 100, with 0 being no pain and 100 being the worst pain possible?

Selected Value: 0

When I am in pain...

I worry all the time about whether the pain will end *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

I feel I can’t go on *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

It’s terrible and I think it’s never going to get any better *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

It’s awful and I feel that it overwhelms me *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

I feel I can’t stand it anymore *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

I become afraid that the pain will get worse *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

I keep thinking of other painful events *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

I anxiously want the pain to go away *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

I can’t seem to get it out of my mind *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

I keep thinking about how much it hurts *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

I keep thinking about how badly I want the pain to stop *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

There’s nothing I can do to reduce the intensity of the pain *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

I wonder whether something serious may happen *

Not at all
To a slight degree
To a moderate degree
To a great degree
All the time

Answer every question by ticking the appropriate box. If you are unsure about how to answer a question, please give the best answer you can or leave it blank.

Symptoms These questions should be answered thinking of your hip symptoms and difficulties during the last week.

Do you feel grinding, hear clicking or any other type of noise from your hip? *

Never
Rarely
Sometimes
Often
Always

Difficulties spreading legs wide apart *

Never
Rarely
Sometimes
Often
Always

Difficulties to stride out when walking *

Never
Rarely
Sometimes
Often
Always

Stiffness The following questions concern the amount of joint stiffness you have experienced during the last week in your hip. Stiffness is a sensation of restriction or slowness in the ease with which you move your hip joint.

How severe is your hip joint stiffness after first waking the morning? *

Never
Rarely
Sometimes
Often
Always

How severe is your hip stiffness after sitting, lying, or resting later in the day? *

Never
Rarely
Sometimes
Often
Always

Pain

How often is your hip painful? *

Never
Monthly
Weekly
Daily
Always

What amount of hip pain have you experienced in the last week during the following activities?

Straightening your hip fully *

Never
Rarely
Sometimes
Often
Always

Bending your hip fully *

Never
Rarely
Sometimes
Often
Always

Walking on a flat surface *

Never
Rarely
Sometimes
Often
Always

Going up or down stairs *

Never
Rarely
Sometimes
Often
Always

Sitting or lying *

Never
Rarely
Sometimes
Often
Always

Standing upright *

Never
Rarely
Sometimes
Often
Always

Walking on a hard surface (asphalt, concrete, etc.) *

Never
Rarely
Sometimes
Often
Always

Walking on an uneven surface *

Never
Rarely
Sometimes
Often
Always

Function, daily living The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your hip.

Descending stairs *

None
Mild
Moderate
Severe
Extreme

Ascending stairs *

None
Mild
Moderate
Severe
Extreme

Rising from sitting *

None
Mild
Moderate
Severe
Extreme

Standing *

None
Mild
Moderate
Severe
Extreme

Bending to the floor / pick up an object *

None
Mild
Moderate
Severe
Extreme

Walking on flat surface *

None
Mild
Moderate
Severe
Extreme

Getting in to / out of the car *

None
Mild
Moderate
Severe
Extreme

Going shopping *

None
Mild
Moderate
Severe
Extreme

Putting on socks / stockings *

None
Mild
Moderate
Severe
Extreme

Rising from bed *

None
Mild
Moderate
Severe
Extreme

Taking off socks / stockings *

None
Mild
Moderate
Severe
Extreme

Lying in bed (turning over, maintaining hip position) *

None
Mild
Moderate
Severe
Extreme

Getting in to / out of the bath *

None
Mild
Moderate
Severe
Extreme

Sitting *

None
Mild
Moderate
Severe
Extreme

Getting on / off the toilet *

None
Mild
Moderate
Severe
Extreme

Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) *

None
Mild
Moderate
Severe
Extreme

Light domestic duties (cooking, dusting, etc) *

None
Mild
Moderate
Severe
Extreme

Function, sports and recreational activities – The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your hip.

Squatting *

None
Mild
Moderate
Severe
Extreme
Not Applicable

Running *

None
Mild
Moderate
Severe
Extreme
Not Applicable

Twisting / pivoting on loaded leg *

None
Mild
Moderate
Severe
Extreme
Not Applicable

Walking on uneven surfaces *

None
Mild
Moderate
Severe
Extreme
Not Applicable

Quality of Life

How often are you aware of your hip problem? *

Never
Monthly
Weekly
Daily
Constantly

Have you modified your lifestyle to avoid potentially damaging activities to your hip? *

Not at all
Mildly
Moderately
Severely
Extremely

How much are you troubled with lack of confidence in your hip? *

Not at all
Mildly
Moderately
Severely
Extremely

In general, how much difficulty do you have with your hip? *

Not at all
Mild
Moderate
Severe
Extreme

Symptoms These questions should be answered thinking of your knee symptoms during the last week.

Do you have swelling in your knee? *

Never
Rarely
Sometimes
Often
Always

Do you feel grinding, hear clicking or any other type of noise when your knee moves? *

Never
Rarely
Sometimes
Often
Always

Does your knee catch or hang up when moving? *

Never
Rarely
Sometimes
Often
Always

Can you straighten your knee fully? *

Never
Rarely
Sometimes
Often
Always

Can you bend your knee fully? *

Never
Rarely
Sometimes
Often
Always

Stiffness The following questions concern the amount of joint stiffness you have experienced during the last week in your knee. Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint.

How severe is your knee joint stiffness after first wakening in the morning? *

None
Mild
Moderate
Severe
Extreme

How severe is your knee stiffness after sitting, lying or resting later in the day? *

None
Mild
Moderate
Severe
Extreme

Pain

How often do you experience knee pain? *

Never
Monthly
Weekly
Daily
Always

What amount of knee pain have you experienced the last week during the following activities?

Twisting / pivoting on your knee *

None
Mild
Moderate
Severe
Extreme

Straightening knee fully *

None
Mild
Moderate
Severe
Extreme

Bending knee fully *

None
Mild
Moderate
Severe
Extreme

Walking on a flat surface *

None
Mild
Moderate
Severe
Extreme

Going up or down stairs *

None
Mild
Moderate
Severe
Extreme

At night while in bed *

None
Mild
Moderate
Severe
Extreme

Sitting or lying *

None
Mild
Moderate
Severe
Extreme

Standing upright *

None
Mild
Moderate
Severe
Extreme

Descending stairs *

None
Mild
Moderate
Severe
Extreme

Ascending stairs *

None
Mild
Moderate
Severe
Extreme

Rising from sitting *

None
Mild
Moderate
Severe
Extreme

Standing *

None
Mild
Moderate
Severe
Extreme

Bending to floor / picking up an object *

None
Mild
Moderate
Severe
Extreme

Walking on a flat surface *

None
Mild
Moderate
Severe
Extreme

Getting in to / out of the car *

None
Mild
Moderate
Severe
Extreme

Going shopping *

None
Mild
Moderate
Severe
Extreme

Putting on socks / stockings *

None
Mild
Moderate
Severe
Extreme

Rising from bed *

None
Mild
Moderate
Severe
Extreme

Taking off socks / stockings *

None
Mild
Moderate
Severe
Extreme

Lying in bed (turning over, maintaining knee position) *

None
Mild
Moderate
Severe
Extreme

Getting in to / out of the bath *

None
Mild
Moderate
Severe
Extreme

Sitting *

None
Mild
Moderate
Severe
Extreme

Getting on / off the toilet *

None
Mild
Moderate
Severe
Extreme

Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) *

None
Mild
Moderate
Severe
Extreme

Light domestic duties (cooking, dusting, etc) *

None
Mild
Moderate
Severe
Extreme

Function, sports and recreational activities The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your knee.

Squatting *

None
Mild
Moderate
Severe
Extreme
Not Applicable

Running *

None
Mild
Moderate
Severe
Extreme
Not Applicable

Jumping *

None
Mild
Moderate
Severe
Extreme
Not Applicable

Twisting / pivoting on your injured knee *

None
Mild
Moderate
Severe
Extreme
Not Applicable

Kneeling *

None
Mild
Moderate
Severe
Extreme
Not Applicable

Quality of Life

How often are you aware of your knee problem? *

Never
Monthly
Weekly
Daily
Constantly

Have you modified your life style to avoid potentially damaging activities to your knee? *

Not at all
Mildly
Moderately
Severely
Extremely

How much are you troubled with lack of confidence in your knee? *

Not at all
Mildly
Moderately
Severely
Extremely

In general, how much difficulty do you have with your knee? *

None
Mild
Moderate
Severe
Extreme