My blood pressure self-management goals Name: Date: My blood pressure 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 0 1 2 3 4 5 Not A Somewhat Very Confident Totally At all Little Confident Confident Confident Follow-up plan (how and when):__________________________ My Next Dr. Apt:_____________________________