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Arthritis Self-Management Workshop
Registration Form - This is 37 questions and will take approximately 30 minutes.
Disclaimer: If you feel uncomfortable with any questions asked, you DO NOT need to answer them.
This is to help tailor the workshop and its presentations towards the participants' best interest.
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* Indicates required question
First and last name, preferred pronouns
*
Your answer
Phone Number
*
Your answer
What is your email address?
*
Your answer
Address or PO Box
Your answer
What kind of arthritis do you have?
Your answer
How long have you been experiencing symptoms?
Less than 6 months
6 months - 1 year
1 year - 5 years
5 years - 10 years
10 years - 15 years
More than 15 years
Clear selection
What symptoms do you experience? (check all that apply)
Pain
Swelling
Inflammation
Fatigue
Other:
Are you currently taking any medications to help manage your condition? If so, which ones?
Your answer
Do you have any questions about your arthritic condition that you would like answered?
Your answer
Are you a member of any arthritis support groups? If so, which ones?
Your answer
Which of the following resources have you found helpful?
Arthritis Organizations
Facebook groups
Social media
Blogs/Vlogs
Medical/Research Articles
Medical resources from doctor's office
Other:
Are there any resources you are interested in learning more about?
Your answer
What do you find most difficult in your daily routine?
Your answer
Are you aware of any websites and resources to get adaptive equipment?
Yes
No
Clear selection
Do use any adaptive equipment currently?
Yes
No
Clear selection
Has any health professional recommended adaptive equipment?
Yes
No
Clear selection
Do you keep a food journal?
Yes
No
Clear selection
What foods do you find make your symptoms worse?
Your answer
What foods do you find make your symptoms better?
Your answer
Do you follow any sort of diet (vegan, keto, gluten-free, etc.)? If yes, what diet? If no, write N/A.
Your answer
Do you have any food allergies or sensitivities? If yes, to what? If no, write N/A.
Your answer
How many days a week do you participate in physical activity?
Your answer
What types of physical activity do you participate in?
Your answer
Even if you do not currently participate in physical activity, are there any types of activities you would be interested in learning more about?
Your answer
What factors prevent you from participating in physical activity?
Your answer
When do you experience the most fatigue during the day?
Morning, soon after waking
Late morning
Afternoon
Evening
Clear selection
Does fatigue limit your ability to complete any of the following? (check all that apply)
Household chores
Maintain employment
Exercise
Participate in desired hobbies/activities
Family time
Other:
Do you experience difficulty sleeping through the night?
Yes
No
Clear selection
What techniques do you use to combat fatigue during the day? (check all that apply)
Schedule tasks according to how much energy they will require
Take naps
Try to maintain a normal sleep schedule
Find alternatives for tasks to reduce their demand on the body
Use adaptive equipment and/or services to make some activities easier
Other:
What is your average pain level each day?
*
No pain
1
2
3
4
5
6
7
8
9
10
Severe pain
How would you describe your pain? (check all that apply)
Burning
Shooting
Aching
Dull
Pins and needles
Other:
Do you experience morning stiffness?
Yes
No
Clear selection
Does your arthritis impact your ability to do daily tasks?
Yes, once a week
Yes, 3-5 times a week
Yes, everyday
Yes, a few times a month
Yes, a few times a year
No, my arthritis does not impact anything
Clear selection
Are there certain movements/activities you've started to avoid to prevent pain? If so, what activities? If not, write N/A.
Your answer
Would you be interested in learning how to cope with anxiety and depression?
Yes
No
Clear selection
Do your currently practice any mental wellness activities?
Yes
No
Clear selection
Are you aware of the signs and symptoms of anxiety and depression?
Yes
No
Clear selection
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