Shared Health Plan - Don Medical Clinic

Developing a Shared Care Plan:

SMART GOALS - how often have all of us had a good intention to do something but somehow we never get to it ?

A Shared Care Plan helps a patient and their care team turn those good intentions into results.

IF you get stuck then email your care team: keepwell@donmedical.com.au

The information you provide will only be available to your care team at Don Medical Clinic.

Name and Date of Birth ( 00/00/00) *

Email Address: *

1. What is the goal that you are working towards over the next 6-12 months ? This may or may not be related to your health but you will need to be well to achieve this goal.

2. What will you do this week in preparation to achieve this goal ?

3. How important is this to you ?

4. So how much what you have decided to do , will you do ?

5.When will you do it ?

6. How often will you do it this week ?

7. If you visualise yourself doing this over the week how confident do you feel that you can achieve this ?

1. Not At All
2. A Little
3. Moderately
4. Mostly
5. Completely

8. What will get in the way ? ( might be more than one thing )

9. What will be the most important barrier ?

10. What might help you to overcome that barrier ?

11. What has helped in the past ?

12. Thank you for completing this survey, do you have any other comments, questions or queries :

Your Message

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