Hispanic Diabetes Disparities Learning Network in Community Health Centers

My Action Plan

Date: _____________

I _________________________________________ and _________________________________________ have agreed that to improve my health I will:
   (patient identification number)                                                   (name of clinician)

1. Choose one of the activities below:

______ Work on something that's bothering me: ______________________

______ Stay more physically active!

______ Take my medications.

______ Improve my food choices.

______ Reduce my stress.

______ Cut down on smoking.

2. Choose your confidence level:

This is how sure that I am that I will be able to do my action plan:

10. Very Sure Image of a ladder; the top of the ladder aligns with 'very sure', and the bottom aligns with 'not sure at all'.  
5. Somewhat Sure
0. Not Sure At All

3. Complete this box for the chosen activity:

What: _______________________________________________________________

How much: _______________________________________________________________

When: _______________________________________________________________

How Often: _______________________________________________________________

Sex: M or F

Age: ______

Hispanic: Yes or No

Page last reviewed October 2014
Internet Citation: My Action Plan. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/diabetesnetwork/actionplan.html