CAPPA questionnaire

Hello! Thank you for your interest in learning more about the Computer-guided Action Planning to Support Physical Activity (CAPPA) trial. We are very excited to meet with you and to share what participation in the trial looks like. Out of respect for your time we would first like to ask several questions to make sure this trial is right for you. If our trial seems like it will be a good fit we will call you within 24 hours of your completion of this form to schedule a time to meet with a research team member to begin participating.

Are you 18 or over years old?

Are you currently employed at Advocate Aurora Health or Marquette University?

Do you receive medical insurance coverage from someone employed at Advocate Aurora Health or Marquette University?

Have you had pain, aching, or stiffness in or around either knee over the past 12 months?

Have you had pain, aching or stiffness in or around knee on most days for at least a month over the past 12 months

Have you had a joint replacement in your symptomatic knee or are you planning to have a joint replacement in the next 12 months?

Has your doctor ever said that you have high blood pressure (Hypertension)?

Has a doctor told you, you have any other issues with your heart?

Please list diagnoses related to heart condition or blood pressure
Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?

Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months?
*Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

Please list other diagnoses here
Are you currently taking prescribed medications for a chronic medical condition?

Please list prescribed medications here
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem - other than knee complaints - that could be made worse by becoming more physically active? *Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

Please list bone, joint, or soft tissue (muscle, ligament, or tendon) problem here that you have or have had in past 12 months that could be made worse with physical activity.
Has your doctor ever said that you should only do medically supervised physical activity?