Personal Care Plan for [text default="patient name"]
1. Set Personal Goals
[select value="Future Goal|Current Goal|Completed Goal"] <-- Improve Functional Ability Score [html]<a href="../../musculoskeletal/faq5-score/" target="_blank">calculator</a>[/html] by [text size="3"] points by: [date]
[select value="Future Goal|Current Goal|Completed Goal"] <-- Return to specific activities, tasks, hobbies, sports... by: [date]
a. [text size=50]
b. [text size=50]
c. [text size=50]
[select value="Future Goal|Current Goal|Completed Goal"] <-- Return to limited work/or normal work by: [date]
2. Improve Sleep (Goal: [select value="1|2|3|4|5|6|7|8|9|10"] hours/night, Current: [select value="1|2|3|4|5|6|7|8|9|10"] hours/night)
[select value="Future Goal|Current Goal|Completed Goal"] <-- Follow basic sleep plan
a. Eliminate caffeine and naps, relaxation before bed, go to bed at target bedtime [text]
[select value="Future Goal|Current Goal|Completed Goal"] <-- Take nighttime medications
a. [text size=50]
b. [text size=50]
c. [text size=50]
3. Increase Physical Activity
[select value="Future Goal|Current Goal|Completed Goal"] <-- Attend physical therapy ([select value="1|2|3|4|5|6|7"] days/week)
[select value="Future Goal|Current Goal|Completed Goal"] <-- Complete daily stretching ([text size="3"] times/day, for [text size="3"] minutes)
[select value="Future Goal|Current Goal|Completed Goal"] <-- Complete aerobic exercise/endurance exercise CHOOSE: [select name="aerobic" value="Walking|Other Exercise"][conditional field="aerobic" condition="(aerobic).is('Walking')"]
a. Walking ([text size=3] times/day, for [text size="3"] minutes) or pedometer ([text size="7"] steps/day)[/conditional][conditional field="aerobic" condition="(aerobic).is('Other Exercise')"]
a. Treadmill, bike, rower, elliptical trainer ([text size="3"] times/week, for [text size="3"] minutes)[/conditional]
b. Target heart rate goal with exercise [text size="3"] bpm [html]<a href="../../cardiovascular/target-heart-rate/" target="_blank">target heart rate calculator</a>[/html]
[select value="Future Goal|Current Goal|Completed Goal"] <-- Strengthening
a. Elastic, hand weights, weight machines ([text size=3] minutes/day, [text size="3"] days/week)
4. Manage Stress – list main stressors [text]
[select value="Future Goal|Current Goal|Completed Goal"] <-- Formal interventions (counseling or classes, support group or therapy group)
a. [text size=50]
[select value="Future Goal|Current Goal|Completed Goal"] <-- Daily practice of relaxation techniques, meditation, yoga, creative activity, service activity, etc.
a. [text size=50]
b. [text size=50]
Medications
a. [text size=50]
b. [text size=50]
[select value="Future Goal|Current Goal|Completed Goal"] <-- 5. Decrease Pain (best pain level in past week: [select value="1|2|3|4|5|6|7|8|9|10"] / 10, worst pain level in past week: [select value="1|2|3|4|5|6|7|8|9|10"] / 10)
Non-medication treatments
a. Ice/heat [text]
b. [text size=50]
Medication
a. [text size=50]
b. [text size=50]
c. [text size=50]
d. [text size=50]
Other treatments [text size=50]
Physician name: [text] Date: [date]