My Personal Wellness Plan -- Worksheet

To be completed by the healthcare professional and patient.
DATE: _____________________________________________________
PATIENT NAME: _____________________________________________
Email Log In (User Name)_____________________________- Password __________
HEALTH OVERVIEW
1. Have you (the patient) been diagnosed with any of the following chronic health problems or diseases?
Hypertension pre-diabetes arthritis cancer type: ________
heart disease type 1 diabetes type 2 diabetes osteoporosis
stroke other ________
2. What is your (the patient’s):
a. Weight_______ Height ___________
b. Hip Measurement__________
c. Waist Measurement ________
d. Blood Pressure Laying ___________; Standing ___________
READINESS AND SUPPORT
3. On a scale of 1-10, 1 being least likely and 10 being most, how likely are you to consider a couple of small lifestyle changes, specifically to increase physical activity and eat healthier, to improve your health?
1 2 3 4 5 6 7 8 9 10
4. On a scale of 1-10, 1 being least supportive and 10 being most, how much support would you receive from your family and friends if they knew you were trying to increase your physical activity and eat healthier?
1 2 3 4 5 6 7 8 9 10
5. On a scale of 1-10, 1 being least receptive and 10 being most, how much support would you like to receive from me should you choose to increase your physical activity and eat healthier?
1 2 3 4 5 6 7 8 9 10
The purpose of this tool is to allow you to have a baseline set of answers (Health Overview) to which to compare at the next patient visit. In addition, the “Readiness and Support” section will give you a basic idea of this patient’s readiness for change.

People who are successful at making lifestyle changes take time to write out specific goals and a plan of action. Use this work sheet to write out your goals and action plans. Review the various area of your health. Decide in which areas you would like to make improvement. List your present situation and specify your goals (what you want to accomplish) in measurable terms.

Keep track of your progress. Review your goals regularly. Get help from others as needed.



Personal wellness plan for: ___________________________
Start date: _____________
Weight Goal: Present weight________ Weight goal in 6 months: ________
Action plans:


Blood Pressure (BP): Present BP ______________ BP goal in 6 months: ________________
Action plans:


Blood Cholesterol: Present Total cholesterol level ________ HDL cholesterol level _________
Goals: Total cholesterol level ________ HDL cholesterol level _________
Action plans:


Lung Volume:____________ Specific things I want to do to improve my maximum volume.
Action plans:


Healthy Eating: Specific things I want to do to improve my eating habits.
Action plans:


Physical Activity: Number of days/week I currently get 30+ min of physical activity ________
Goals: Active 30+ min ______ days/week Kinds of activities: ___________________________
Action plans:


Stress and Coping: Ways I can improve mental/emotional health and coping skills such as daily
relaxation, recreation, hobbies, social interaction, and avoid habits that waste productive living.
Action plans:


Preventive Exams: Health tests and exams I want to do to keep current in my preventive exams:
Action plans:


Addictive Behaviors: Habits I would like to change that seem to control me such as smoking,
alcohol, drugs, gambling, binge eating, excessive work that damages my health and family life,
or excessive TV viewing.
Action plans:

Spiritual Health: Values, virtues, or service to others I would like to incorporate into my life
that would provide meaning, purpose, peace, and enrichment to my life and to others.
Action plans:
Other Changes:


Commitment: I choose to implement these wellness goals to the best of my ability. I agree to allowing this report to be submitted to my PCP.
______________________________ ________________ ________________________
(Your signature) (Date) (Wellness Coach)
.