Self Assessment Step 1 of 8 12% This self-assessment is a useful tool to record your baseline measures. Not only will this give you guidance on your current status, but it provides an opportunity for comparison at the end of the 10 Week Challenge. The feedback we generally receive is that at the end of the 10 Week Challenge people feel better, have more energy and they are receiving feedback from friends and family that they look better and brighter. These are the sorts of subjective improvements we hope you will achieve in the 10 Week Challenge! The Self-assessment will help to put some numbers around feedback from others and how you feel in yourself. For this reason, it is important you complete your self-assessment before and after the 10 Week Challenge and where possible try to conduct the assessment at similar times of day to limit any effects your medication may provide. With these concrete measurements you will know at the end of the 10 weeks if you have made “clinical” gains or not. Not only will this help your own motivation, it will help to see how well you are doing and if you need some further tweaks to your program. For the physical section you will require the following 10m track marked out Stop watch or watch with second hand Tissue box or foam block of similar size Please make sure that you only work within your limits and personal safety. If at any time, you do not feel safe, feel unbalanced or feel pain or discomfort, please discontinue the task. If possible, have a buddy close and available for safety. You will find it easier to complete these tests with a second person assisting you for timing and recording support. To conduct these tests, please mark out a track that measures 10 metres (with an additional 2m clearance on either side). You can do this inside or out but please make sure that your track is flat, clear of obstacles, debris or tripping hazards and can be available for use for re-testing in future.This field is hidden when viewing the formFull NameThis field is hidden when viewing the formEmail Date MM slash DD slash YYYY Which Assessment is this for you? Initial Assessment (Pre - 10 Week Challenge) Final Assessment (Post - 10 Week Challenge) I agree to and understand the exercise disclaimer provided.(Required) I agree to and understand the exercise disclaimer provided. QUESTIONNAIRE SECTIONThe following questions have been developed specifically to assess your daily activity and confidence in getting around. Please read the questions carefully and answer as precisely as you can. If you need to stop, please pause and return to the questions when you feel ready. 1. Modified Incidental and Planned Activity In the last week, how often have you participated in scheduled activities such as exercise classes, bowls, golf, tennis, swimming, dancing, walking or jogging for exercise, bicycling etc. Every day 3 - 6 times per week Twice per week Once per week Less than once per week Never During the last week, how long did you spend doing these scheduled activities? Never Less than 15 mins per day 15 mins to less than 30 mins per day 30 mins to less than 1 hour per day 1 hour to less than 2 hours per day 2 hours to less than 4 hours per day 4 or more hours per day In the last week, how often have you participated in incidental activity such as house work, walking for pleasure or errands, gardening or community work etc? Every day Six times Five times Four times Three times Twice Once Never During the last week, how long did you spend doing these scheduled activities? Never Less than 15 mins per day 15 mins to less than 30 mins per day 30 mins to less than 1 hour per day 1 hour to less than 2 hours per day 2 hours to less than 4 hours per day 4 or more hours per day If using an activity tracker, smart watch, phone or pedometre, please enter the average number of steps taken in the past three days. 2. PDQ-8Due to having Parkinson's, how often during the last month have you...NeverOccasionallySometimesOftenAlways (or cannot do at all)Had difficulty getting around in public?Had difficulty dressing yourself?Felt depressed?Had problems with your close personal relationships?Had problems with your concentration eg when reading, watching TV?Felt unable to communicate with people properly?Had painful muscle cramps or spasms?Felt embarrassed in public due to having Parkinson's disease? 3. Self Assessment Parkinson's Function (MSPPDS)Please rate the degree of difficulty you have doing each of these activities in general. If you use a mobility aid, please answer how well you would manage without your aidAble to do aloneAlone but minimally difficultDifficult or with helpOnly able with a lot of helpUnable to do at allGetting out of bedGetting up from a low chairWalking around the houseWalking around outside eg. to the shopsGetting dressed or undressedGetting on or off the floorHolding a cup and saucerPreparing a simple mealCutting food with knife and forkPick up an object from the floorWalking on an uneven or slippery surface (e.g. rocky ground, poorly maintained pavement, wet surface)Walking in a place with crowdsTravelling by public transportWriting a letterTurning over in bedConcentrating eg when reading, watching TV? 4. Falls & FreezingHave you fallen in the past 12 months? Yes - Once Yes - More than once No How concerned are you about the possibility of falling?1 is Very concerned, 5 is Not concerned at all 1 2 3 4 5 Have you experienced freezing of gait in the past month (feet sticking to the floor)?(Required) Yes No During your worst state—Do you walk: Normally Almost normally—somewhat slow Slow but fully independent Need assistance or walking aid Unable to walk Are your gait difficulties affecting your daily activities and independence? Not at all Mildly Moderately Severely Unable to walk Do you find that when your medication is wearing OFF, you experience more freezing? Yes, I freeze when my medication if wearing off No, medication timing does not seem to make a difference Other Do you feel that your feet get glued to the fl oor while walking, making a turn or when trying to initiate walking (freezing)? Never Very rarely—about once a month Rarely—about once a week Often—about once a day Always—whenever walking When do you typically find that your feet stick to the floor? When turning When you try to start walking When there is a lot of noise and movement around you? When there is a change of floor surface or narrowing environment like a door frame? When you have been walking in an open space for some time Other 5. PHYSICAL SECTION For the next section you will need to perform various physical tasks. Please make sure that you only work within your limits and personal safety. If at any time, you do not feel safe, feel unbalanced or feel pain or discomfort, please discontinue the task. If possible, have a buddy close and available for safety. You will find it easier to complete these tests with a second person assisting you for timing and recording support. It is best to complete these tests before you start the 10 week challenge as well as on completion so that you can compare. Please keep to similar times of day to perform the tests to limit any effects your medication may provide. To conduct these tests, please mark out a track that measures 10 metres (with an additional 2m clearance on either side). You can do this inside or out but please make sure that your track is flat, clear of obstables, debris or tripping hazards and can be available for use for re-testing in future. 10m walk test Walking along your track, starting from the clearance end (-2m) all the way to the other end of the clearance area (+2m) at a comfortable walking speed. Take a measure of the time to complete the distance between the middle 10 metre section of your track, as well as the number of steps to complete the middle 10 metre distance. If you have a second person, have them record both the time and number of steps taken. Repeat this task 3 times and average the times to get a single result. How many seconds did you average over the middle 10m distance?How many steps did you average over the middle 10m distance?Six minute walk test The object of this test is to walk as quickly as you can for six minutes back and forth along the track so that you cover as much ground as possible. You may slow down or take a rest if necessary. If you stop, please continue to walk again as soon as possible. Your goal is to walk as far as possible in six minutes. Please do not talk during the test unless you have a problem. Remember - You must stop the test if you have any chest pain or dizziness. When the six minutes is up please stop where you are and take your final distance measurement.How many metres did you cover in 6 minutes?Balance Test Sit to stand - Sit on a regular dining room height chair. Cross your arms across your chest. Try not to use your hands unless you must. Do not let your legs lean against the back of the chair when you stand. Stand up to full height and sit down again as fast as you can five times. Record your time to do this. How long does it take you to sit to stand independently x 5 without using your hands?Step tap - stand a tissue box on end in front of you (26cm tall roughly). Tap the top of the box with alternating feet as fast as you can without crushing the box, knocking it over or losing your balance eight (8) times (4 taps for each foot). Record your time to do this. Can you tap the box 8 times in total in under 20 seconds? Yes No Goals Please identify and rate three important activities on a scale from 0 to 10 that you are unable to do or are having difficulty with as a result of your Parkinson's. These are tasks that you would like to be able to do by conducting PD Warrior exercise.Activity 1Activity 1Please identify and rate three important activities on a scale from 1 (Unable) to 10 (Able) that you are having difficulty with as a result of your Parkinson's. These are tasks that you would like to be able to do/do better after completing the PD Warrior 10 Week Challenge. 1 2 3 4 5 6 7 8 9 10 Activity 2Activity 2Please identify and rate three important activities on a scale from 1 (Unable) to 10 (Able) that you are having difficulty with as a result of your Parkinson's. These are tasks that you would like to be able to do/do better after completing the PD Warrior 10 Week Challenge. 1 2 3 4 5 6 7 8 9 10 Activity 3Activity 3Please identify and rate three important activities on a scale from 1 (Unable) to 10 (Able) that you are having difficulty with as a result of your Parkinson's. These are tasks that you would like to be able to do/do better after completing the PD Warrior 10 Week Challenge. 1 2 3 4 5 6 7 8 9 10
