Welcome to your first week of the MotionPlus program! CLICK HERE to download the week one readingComplete the questions under week one in your Activity BookProvide the information requested in the form below Please enable JavaScript in your browser to complete this form.Patient Information - Step 1 of 7Today's Date *Name *FirstLastEmail *Date of Birth *My weight today is (kg)... *My height is (cm)... *My Patient Partner is... *NameAmy GoldstromAndrew ChaplainAndy BrittenBrad DennienEmma CarragherJason SharpJoanne PageJuliette BalohKatrina McInnesKurt DrinkwaterLacey MorrisLaura EsplinLeah CurtisLu-Inge KillianMeagan MorseMehmed DulicPierce FitzgeraldRonan BriodySamuel Di NataleThomas CyprienTodd NixMy surgeon is... *What type of pain do you have? *KneeHipWhat side is your pain on? *LeftRightBothNextPlease indicate which statement best describes your own health state todayMobility *I have no problems in walking aboutI have slight problems in walking aboutI have moderate problems in walking aboutI have severe problems in walking aboutI am unable to walk aboutSelf Care *I have no problems in washing or dressing myselfI have slight problems in washing or dressing myselfI have moderate problems in washing or dressing myselfI have severe problems in washing or dressing myselfI am unable to walk about wash or dress myselfUsual Activities (eg. work, study, housework, family or leisure activities) *I have no problems in doing my usual activitiesI have slight problems in doing my usual activitiesI have moderate problems in doing my usual activitiesI have severe problems in doing my usual activitiesI am unable to do my usual activitiesPain / Discomfort *I have no pain or discomfortI have slight pain or discomfortI have moderate pain or discomfortI have severe pain or discomfortI have extreme pain or discomfortAnxiety / Depression *I am not anxious or depressedI am slightly anxious or depressedI am moderatly anxious or depressedI am severely anxious or depressedI am extremely anxious or depressedWe would like you to indicate how good or bad your own health is today, in your opinion. *0 (Worst imaginable)102030405060708090100 (Best imaginable)PreviousNext Overall Health - If you are unsure how to answer a question, please give the best answer you canIn general, would you say your health is... *ExcellentVery GoodGoodFairPoorThe 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 lotYes, limited a littleNo, not limited at allDoes your health now limit you in climbing SEVERAL flights of stairs? *Yes, limited a lotYes, limited a littleNo, not limited at allDuring 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 timeMost of the timeSome of the timeOnly a little of the timeNone 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 timeMost of the timeSome of the timeOnly a little of the timeNone of the timeDuring 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 timeMost of the timeSome of the timeOnly a little of the timeNone of the timeOver 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 timeMost of the timeSome of the timeOnly a little of the timeNone of the timeOver the last four weeks, how much did PAIN interfere with your house work and work outside the home? *Not at allA little bitModeratelyQuite a bitExtremelyThese 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 timeMost of the timeSome of the timeOnly a little of the timeNone of the timeOver the last four weeks, how often have you had a lot of energy? *All of the timeMost of the timeSome of the timeOnly a little of the timeNone of the timeOver the last four weeks, how often have you felt downhearted and depressed? *All of the timeMost of the timeSome of the timeOnly a little of the timeNone of the timeOver 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 timeMost of the timeSome of the timeOnly a little of the timeNone of the timePreviousNextBelow 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/AWhen all is said and done, I am the person who is responsible for taking care of my health *Disagree StronglyDisagreeAgreeAgree StronglyN/ATaking an active role in my own health care is the most important thing that affects my health *Disagree StronglyDisagreeAgreeAgree StronglyN/AI know what each of my prescribed medications do *Disagree StronglyDisagreeAgreeAgree StronglyN/AI 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 StronglyDisagreeAgreeAgree StronglyN/AI am confident that I can tell a doctor my concerns , even when he or she does not ask *Disagree StronglyDisagreeAgreeAgree StronglyN/AI am confident that I can follow through on medical treatments I may need to do at home *Disagree StronglyDisagreeAgreeAgree StronglyN/AI have been able to maintain (keep up with) lifestyle changes, like eating right or exercising *Disagree StronglyDisagreeAgreeAgree StronglyN/AI know how to prevent problems with my health *Disagree StronglyDisagreeAgreeAgree StronglyN/AI am confident that I can figure out solutions when new problems arise with my health *Disagree StronglyDisagreeAgreeAgree StronglyN/AI am confident that I can maintain lifestyle changes, like eating right and exercising, even during times of stress *Disagree StronglyDisagreeAgreeAgree StronglyN/APreviousNextHow 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 PreviousNextWhen I am in pain...I worry all the time about whether the pain will end *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeI feel I can’t go on *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeIt’s terrible and I think it’s never going to get any better *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeIt’s awful and I feel that it overwhelms me *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeI feel I can’t stand it anymore *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeI become afraid that the pain will get worse *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeI keep thinking of other painful events *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeI anxiously want the pain to go away *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeI can’t seem to get it out of my mind *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeI keep thinking about how much it hurts *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeI keep thinking about how badly I want the pain to stop *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeThere’s nothing I can do to reduce the intensity of the pain *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timeI wonder whether something serious may happen *Not at allTo a slight degreeTo a moderate degreeTo a great degreeAll the timePreviousNextAnswer 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? *NeverRarelySometimesOftenAlwaysDifficulties spreading legs wide apart *NeverRarelySometimesOftenAlwaysDifficulties to stride out when walking *NeverRarelySometimesOftenAlwaysStiffness 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? *NeverRarelySometimesOftenAlwaysHow severe is your hip stiffness after sitting, lying, or resting later in the day? *NeverRarelySometimesOftenAlwaysPainHow often is your hip painful? *NeverMonthlyWeeklyDailyAlwaysWhat amount of hip pain have you experienced in the last week during the following activities?Straightening your hip fully *NeverRarelySometimesOftenAlwaysBending your hip fully *NeverRarelySometimesOftenAlwaysWalking on a flat surface *NeverRarelySometimesOftenAlwaysGoing up or down stairs *NeverRarelySometimesOftenAlwaysSitting or lying *NeverRarelySometimesOftenAlwaysStanding upright *NeverRarelySometimesOftenAlwaysWalking on a hard surface (asphalt, concrete, etc.) *NeverRarelySometimesOftenAlwaysWalking on an uneven surface *NeverRarelySometimesOftenAlwaysFunction, 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 *NoneMildModerateSevereExtremeAscending stairs *NoneMildModerateSevereExtreme Rising from sitting *NoneMildModerateSevereExtremeStanding *NoneMildModerateSevereExtremeBending to the floor / pick up an object *NoneMildModerateSevereExtremeWalking on flat surface *NoneMildModerateSevereExtremeGetting in to / out of the car *NoneMildModerateSevereExtremeGoing shopping *NoneMildModerateSevereExtremePutting on socks / stockings *NoneMildModerateSevereExtremeRising from bed *NoneMildModerateSevereExtremeTaking off socks / stockings *NoneMildModerateSevereExtremeLying in bed (turning over, maintaining hip position) *NoneMildModerateSevereExtreme Getting in to / out of the bath *NoneMildModerateSevereExtremeSitting *NoneMildModerateSevereExtremeGetting on / off the toilet *NoneMildModerateSevereExtremeHeavy domestic duties (moving heavy boxes, scrubbing floors, etc) *NoneMildModerateSevereExtremeLight domestic duties (cooking, dusting, etc) *NoneMildModerateSevereExtremeFunction, 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 *NoneMildModerateSevereExtremeNot ApplicableRunning *NoneMildModerateSevereExtremeNot ApplicableTwisting / pivoting on loaded leg *NoneMildModerateSevereExtremeNot ApplicableWalking on uneven surfaces *NoneMildModerateSevereExtremeNot ApplicableQuality of Life How often are you aware of your hip problem? *NeverMonthlyWeeklyDailyConstantlyHave you modified your lifestyle to avoid potentially damaging activities to your hip? *Not at allMildlyModeratelySeverelyExtremelyHow much are you troubled with lack of confidence in your hip? *Not at allMildlyModeratelySeverelyExtremely In general, how much difficulty do you have with your hip? *Not at allMildModerateSevereExtremeSymptoms These questions should be answered thinking of your knee symptoms during the last week.Do you have swelling in your knee? *NeverRarelySometimesOftenAlwaysDo you feel grinding, hear clicking or any other type of noise when your knee moves? *NeverRarelySometimesOftenAlwaysDoes your knee catch or hang up when moving? *NeverRarelySometimesOftenAlwaysCan you straighten your knee fully? *NeverRarelySometimesOftenAlwaysCan you bend your knee fully? *NeverRarelySometimesOftenAlwaysStiffness 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? *NoneMildModerateSevereExtremeHow severe is your knee stiffness after sitting, lying or resting later in the day? *NoneMildModerateSevereExtremePainHow often do you experience knee pain? *NeverMonthlyWeeklyDailyAlwaysWhat amount of knee pain have you experienced the last week during the following activities?Twisting / pivoting on your knee *NoneMildModerateSevereExtremeStraightening knee fully *NoneMildModerateSevereExtremeBending knee fully *NoneMildModerateSevereExtremeWalking on a flat surface *NoneMildModerateSevereExtremeGoing up or down stairs *NoneMildModerateSevereExtremeAt night while in bed *NoneMildModerateSevereExtremeSitting or lying *NoneMildModerateSevereExtremeStanding upright *NoneMildModerateSevereExtremeFunction, 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 knee.Descending stairs *NoneMildModerateSevereExtremeAscending stairs *NoneMildModerateSevereExtremeRising from sitting *NoneMildModerateSevereExtremeStanding *NoneMildModerateSevereExtremeBending to floor / picking up an object *NoneMildModerateSevereExtremeWalking on a flat surface *NoneMildModerateSevereExtremeGetting in to / out of the car *NoneMildModerateSevereExtremeGoing shopping *NoneMildModerateSevereExtremePutting on socks / stockings *NoneMildModerateSevereExtremeRising from bed *NoneMildModerateSevereExtremeTaking off socks / stockings *NoneMildModerateSevereExtremeLying in bed (turning over, maintaining knee position) *NoneMildModerateSevereExtremeGetting in to / out of the bath *NoneMildModerateSevereExtremeSitting *NoneMildModerateSevereExtremeGetting on / off the toilet *NoneMildModerateSevereExtremeHeavy domestic duties (moving heavy boxes, scrubbing floors, etc) *NoneMildModerateSevereExtreme Light domestic duties (cooking, dusting, etc) *NoneMildModerateSevereExtremeFunction, 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 *NoneMildModerateSevereExtremeNot ApplicableRunning *NoneMildModerateSevereExtremeNot ApplicableJumping *NoneMildModerateSevereExtremeNot ApplicableTwisting / pivoting on your injured knee *NoneMildModerateSevereExtremeNot ApplicableKneeling *NoneMildModerateSevereExtremeNot ApplicableQuality of Life How often are you aware of your knee problem? *NeverMonthlyWeeklyDailyConstantlyHave you modified your life style to avoid potentially damaging activities to your knee? *Not at allMildlyModeratelySeverelyExtremelyHow much are you troubled with lack of confidence in your knee? *Not at allMildlyModeratelySeverelyExtremelyIn general, how much difficulty do you have with your knee? *NoneMildModerateSevereExtremeSubmit