1. TOOL FOR ENGAGING STAFF/CLIENTS IN DISCUSSION OF SELF-MANAGEMENT GOALS
PORT ALBERNI TEAM

2. We Stole:
The topic list developed for group workshops by the Native Health Center

3. We wove those topics into a colorful, quick client survey form

4. Rate Your Satisfaction with your Health Status
A. Your knowledge of HIV
B. Your understanding of your HIV medications
C. Your nutritional status
D. Your level of physical activity

5. E. The safety of your sexual practices
F. Your ability to manage your time, work, money
G. Your emotional health

6. We use the survey as a jumping-off point for discussion of self- management goals

7. We use the back-side of the survey form to record the 1 goal that is chosen to be worked on for the next quarter
Date of Survey:
Goal:
First Steps:
Resources:

8. At the next visit we review how things are going with meeting the self-management goal

9. In 3 months the survey is repeated
Rate Your Satisfaction with your Health Status