Tools

Action Plan
This short form helps people with chronic conditions develop and record changes they plan to make or goals they want to achieve. The form can be used during a health care visit and then copied so the patient has a copy to take home. It can also be included in their chart to support follow-up. An example of a completed form is included.

Conviction Confidence Ruler
This tool helps patients and providers discuss and rate two issues related to goal setting and healthy changes – how convinced a patient is that the change is necessary or important and how confident they are in their ability to achieve the goal.

Self Management Support
This form, developed at Improving Chronic Illness Care program in Seattle Washington, helps people with chronic conditions develop a personal plan to learn a new behavior, such as starting a program to increase their physical activity.

The Healthy Changes Plan form may be used by patients either at home or during their office visit to plan their self-management goals for managing their chronic condition.

Self-Management Support Documentation Form
Mercy Clinics, Inc. in Des Moines, Iowa created this easy-to-use form to document self-management goals, patient's level of confidence and readiness, problem-solving strategies, and follow-up plans.