Personal Care Plan for
1. Set Personal Goals
<-- Improve Functional Ability Score calculator by points by:
<-- Return to specific activities, tasks, hobbies, sports... by:
a.
b.
c.
<-- Return to limited work/or normal work by:
2. Improve Sleep (Goal: hours/night, Current: hours/night)
<-- Follow basic sleep plan
a. Eliminate caffeine and naps, relaxation before bed, go to bed at target bedtime
<-- Take nighttime medications
a.
b.
c.
3. Increase Physical Activity
<-- Attend physical therapy ( days/week)
<-- Complete daily stretching ( times/day, for minutes)
<-- Complete aerobic exercise/endurance exercise CHOOSE:
a. Walking ( times/day, for minutes) or pedometer ( steps/day)
b. Target heart rate goal with exercise bpm
<-- Strengthening
a. Elastic, hand weights, weight machines ( minutes/day, days/week)
4. Manage Stress – list main stressors
<-- Formal interventions (counseling or classes, support group or therapy group)
a.
<-- Daily practice of relaxation techniques, meditation, yoga, creative activity, service activity, etc.
a.
b.
Medications
a.
b.
<-- 5. Decrease Pain (best pain level in past week: / 10, worst pain level in past week: / 10)
Non-medication treatments
a. Ice/heat
b.
Medication
a.
b.
c.
d.
Other treatments
Physician name: Date:

Result - Copy and paste this output: