Date: _____________
I _________________________________________ and _________________________________________ have agreed that to improve my health I will:
(patient identification number) (name of clinician)
1. Choose one of the activities below:
______ Work on something that's bothering me: ______________________
______ Stay more physically active!
______ Take my medications.
______ Improve my food choices.
______ Reduce my stress.
______ Cut down on smoking.
2. Choose your confidence level:
This is how sure that I am that I will be able to do my action plan:
10. Very Sure | |
5. Somewhat Sure | |
0. Not Sure At All |
3. Complete this box for the chosen activity:
What: _______________________________________________________________
How much: _______________________________________________________________
When: _______________________________________________________________
How Often: _______________________________________________________________
Sex: M or F
Age: ______
Hispanic: Yes or No