1. My cardiovascular self-management goals
Name: Date:
My cardiovascular self-management goals
Eat a Healthy Diet
(DASH) with less salt
Take My Medicine
Everyday
Be Physically
Active
Reduce Stress
See My Dr.
Tell Doctor & Pharmacist
about any herbals or Over The Counter Meds
I need help
Monitor Blood
Pressure
Stop Smoking
My Goal
One way I want to improve my health is (e.g. be more active):
____________________________________________________
My goal for each day/this week is (e.g. walk 4 times):
___________________________________________________
When will I do it (e.g. in the morning):____________________
Where I will do it (e.g. at the park):_______________________
How will I remember to do it (e.g. use a pill box):
What might get in the way of the goal (e.g. not being home):
What can I do about it (e.g. choose another day to be active):
How confident am I that I can reach this goal: circle one
Not A Somewhat Very Confident Totally
At all Little Confident Confident Confident
Follow-up plan (how and when):__________________________
My Next Dr. Apt:_____________________________