1. 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
Not A Somewhat Very Confident Totally
At all Little Confident Confident Confident
Follow-up plan (how and when):__________________________
My Next Dr. Apt:_____________________________