My asthma self-management goals Name: Date: My asthma self-management goals Take My Medicine I will know the names of my medications ,what they do, and how to take them the right way Be Physically Active-take breaks as needed Reduce Stress See My Dr. Avoid My Triggers Follow My Asthma Action Plan My Goal I need help Stop Smoking 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:_____________________________