pulmonary rehabilitation program home exercise diary · 2017-10-01 · pulmonary rehabilitation...
TRANSCRIPT
Pulmonary Rehabilitation Program
Home Exercise Diary
Program contact:
__________________________________________
__________________________________________
HomeBase – Last reviewed October 2017 2
In this booklet you will find:
(1) The time of your weekly telephone call
(2) Instructions on how to monitor your health and ensure you
are well enough to exercise
(3) A diary to record how much exercise you are doing
(4) Contact information for enquires or assistance.
HomeBase – Last reviewed October 2017 3
My appointments
My weekly telephone call from the health professional:
Day:_____________________________________________________________________
Time:____________________________________________________________________
Date of first call:________________________________________________________
Date of last call:_________________________________________________________
If you are unable to keep this telephone appointment, please inform:
Name:_____________________________________________________________________
Name:_____________________________________________________________________
Ph:_________________________________________________________________________
Ph:_________________________________________________________________________
You may also ring these telephone numbers if you have any other
queries or concerns during the program.
HomeBase – Last reviewed October 2017 4
Hospital assessment:
Date:_____________________________________________________________
Time:______________________________________________________________
Location:__________________________________________________________
8 week assessment:
Date:_______________________________________________________________
Time:______________________________________________________________
Location:__________________________________________________________
HomeBase – Last reviewed October 2017 5
Before you exercise
Exercise is not recommended if you have a chest infection or a flare up of your
lung condition that has not been treated. Before you exercise, please ensure you
have checked that you do not have any symptoms of a flare up.
Warning signs for a moderate flare up:
• more wheezy or breathless than normal
• increased cough or sputum, change in colour of sputum
• loss of appetite or difficulty sleeping
• taking more reliever medication than normal
If you have any of these warning signs of a moderate flare up, please do not start
your exercise. Instead, ring:
Name: _______________________________________________________________
Ph:____________________________________________________________________
The health professional may ask you to contact your local doctor or respiratory specialist.
Warning signs for a severe flare up:
• unable to perform normal activities like bathing and dressing
• fever or chills
• increased swelling of ankles
• extremely short of breath
If you have any of these warning signs of a severe flare up, please call the
emergency number in your area ______________and tell them you have COPD.
HomeBase – Last reviewed October 2017 6
Notes:_____________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
HomeBase – Last reviewed October 2017 7
Week 1 – My Exercise Goals
My exercise goal for this week is: ________________________________________________________________
____________________________________________________________________________________________
When I will do my exercise:______________________________________________________________________
Where I will do my exercise:______________________________________________________________________
How often I will do my exercise:___________________________________________________________________
What might get in the way of my plan:______________________________________________________________
What I can do about it:___________________________________________________________________________
How confident am I that I can achieve my exercise goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 8
HomeBase – Last reviewed October 2017 9
Week 1 – My Exercise Diary
Day Date
Monday / /
Tuesday / /
Wednesday / /
Thursday / /
Friday / /
Saturday / /
Sunday / /
Moderate flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Severe flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
If you answer ‘yes’, please follow the instructions on page 5.
My endurance exercises Type:______________________
Duration: (goal)______________
Steps/distance: (goal)_________
Breathing score: (goal)________
Leg score: (goal)_____________
My strengthening exercises 1.
2.
3.
4.
5.
Comments
HomeBase – Last reviewed October 2017 10
Week 2 – My Exercise Goals
My exercise goal for this week is: ________________________________________________________________
When I will do my exercise:______________________________________________________________________
Where I will do my exercise:______________________________________________________________________
How often I will do my exercise:___________________________________________________________________
What might get in the way of my plan:______________________________________________________________
What I can do about it:___________________________________________________________________________
How confident am I that I can achieve my exercise goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 11
Week 2 – My Health Goals
One way I want to improve my health is:________________________________________________________
My health goal for this week is: _______________________________________________________________
When I will do it:____________________________________________________________________________
Where I will do it:____________________________________________________________________________
How often I will do it:_________________________________________________________________________
What might get in the way of my plan:____________________________________________________________
What I can do about it:_________________________________________________________________________
How confident am I that I can achieve this goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 12
Week 2 – My Exercise Diary
Day Date
Monday / /
Tuesday / /
Wednesday / /
Thursday / /
Friday / /
Saturday / /
Sunday / /
Moderate flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Severe flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
If you answer ‘yes’, please follow the instructions on page 5.
My endurance exercises Type:______________________
Duration: (goal)______________
Steps/distance: (goal)_________
Breathing score: (goal)________
Leg score: (goal)_____________
My strengthening exercises 1.
2.
3.
4.
5.
Comments
HomeBase – Last reviewed October 2017 13
Week 3 – My Exercise Goals
My exercise goal for this week is: ________________________________________________________________
When I will do my exercise:______________________________________________________________________
Where I will do my exercise:______________________________________________________________________
How often I will do my exercise:___________________________________________________________________
What might get in the way of my plan:______________________________________________________________
What I can do about it:___________________________________________________________________________
How confident am I that I can achieve my exercise goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 14
Week 3 – My Health Goals
One way I want to improve my health is:________________________________________________________
My health goal for this week is: _______________________________________________________________
When I will do it:____________________________________________________________________________
Where I will do it:____________________________________________________________________________
How often I will do it:_________________________________________________________________________
What might get in the way of my plan:____________________________________________________________
What I can do about it:_________________________________________________________________________
How confident am I that I can achieve this goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 15
Week 3 – My Exercise Diary
Day Date
Monday / /
Tuesday / /
Wednesday / /
Thursday / /
Friday / /
Saturday / /
Sunday / /
Moderate flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Severe flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
If you answer ‘yes’, please follow the instructions on page 5.
My endurance exercises Type:______________________
Duration: (goal)______________
Steps/distance: (goal)_________
Breathing score: (goal)________
Leg score: (goal)_____________
My strengthening exercises 1.
2.
3.
4.
5.
Comments
HomeBase – Last reviewed October 2017 16
HomeBase – Last reviewed October 2017 17
Week 4 – My Exercise Goals
My exercise goal for this week is: ________________________________________________________________
When I will do my exercise:______________________________________________________________________
Where I will do my exercise:______________________________________________________________________
How often I will do my exercise:___________________________________________________________________
What might get in the way of my plan:______________________________________________________________
What I can do about it:___________________________________________________________________________
How confident am I that I can achieve my exercise goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 18
Week 4 – My Health Goals
One way I want to improve my health is:________________________________________________________
My health goal for this week is: _______________________________________________________________
When I will do it:____________________________________________________________________________
Where I will do it:____________________________________________________________________________
How often I will do it:_________________________________________________________________________
What might get in the way of my plan:____________________________________________________________
What I can do about it:_________________________________________________________________________
How confident am I that I can achieve this goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 19
Week 5 – My Exercise Diary
Day Date
Monday / /
Tuesday / /
Wednesday / /
Thursday / /
Friday / /
Saturday / /
Sunday / /
Moderate flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Severe flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
If you answer ‘yes’, please follow the instructions on page 5.
My endurance exercises Type:______________________
Duration: (goal)______________
Steps/distance: (goal)_________
Breathing score: (goal)________
Leg score: (goal)_____________
My strengthening exercises 1.
2.
3.
4.
5.
Comments
HomeBase – Last reviewed October 2017 20
Week 5 – My Exercise Goals
My exercise goal for this week is: ________________________________________________________________
When I will do my exercise:______________________________________________________________________
Where I will do my exercise:______________________________________________________________________
How often I will do my exercise:___________________________________________________________________
What might get in the way of my plan:______________________________________________________________
What I can do about it:___________________________________________________________________________
How confident am I that I can achieve my exercise goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 21
Week 5 – My Health Goals
One way I want to improve my health is:________________________________________________________
My health goal for this week is: _______________________________________________________________
When I will do it:____________________________________________________________________________
Where I will do it:____________________________________________________________________________
How often I will do it:_________________________________________________________________________
What might get in the way of my plan:____________________________________________________________
What I can do about it:_________________________________________________________________________
How confident am I that I can achieve this goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 22
Week 5 – My Exercise Diary
Day Date
Monday / /
Tuesday / /
Wednesday / /
Thursday / /
Friday / /
Saturday / /
Sunday / /
Moderate flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Severe flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
If you answer ‘yes’, please follow the instructions on page 5.
My endurance exercises Type:______________________
Duration: (goal)______________
Steps/distance: (goal)_________
Breathing score: (goal)________
Leg score: (goal)_____________
My strengthening exercises 1.
2.
3.
4.
5.
Comments
HomeBase – Last reviewed October 2017 23
Week 6 – My Exercise Goals
My exercise goal for this week is: ________________________________________________________________
When I will do my exercise:______________________________________________________________________
Where I will do my exercise:______________________________________________________________________
How often I will do my exercise:___________________________________________________________________
What might get in the way of my plan:______________________________________________________________
What I can do about it:___________________________________________________________________________
How confident am I that I can achieve my exercise goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 24
Week 6 – My Health Goals
One way I want to improve my health is:________________________________________________________
My health goal for this week is: _______________________________________________________________
When I will do it:____________________________________________________________________________
Where I will do it:____________________________________________________________________________
How often I will do it:_________________________________________________________________________
What might get in the way of my plan:____________________________________________________________
What I can do about it:_________________________________________________________________________
How confident am I that I can achieve this goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 25
Week 6 – My Exercise Diary
Day Date
Monday / /
Tuesday / /
Wednesday / /
Thursday / /
Friday / /
Saturday / /
Sunday / /
Moderate flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Severe flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
If you answer ‘yes’, please follow the instructions on page 5.
My endurance exercises Type:______________________
Duration: (goal)______________
Steps/distance: (goal)_________
Breathing score: (goal)________
Leg score: (goal)_____________
My strengthening exercises 1.
2.
3.
4.
5.
Comments
HomeBase – Last reviewed October 2017 26
HomeBase – Last reviewed October 2017 27
Week 7 – My Exercise Goals
My exercise goal for this week is: ________________________________________________________________
When I will do my exercise:______________________________________________________________________
Where I will do my exercise:______________________________________________________________________
How often I will do my exercise:___________________________________________________________________
What might get in the way of my plan:______________________________________________________________
What I can do about it:___________________________________________________________________________
How confident am I that I can achieve my exercise goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 28
Week 7 – My Health Goals
One way I want to improve my health is:________________________________________________________
My health goal for this week is: _______________________________________________________________
When I will do it:____________________________________________________________________________
Where I will do it:____________________________________________________________________________
How often I will do it:_________________________________________________________________________
What might get in the way of my plan:____________________________________________________________
What I can do about it:_________________________________________________________________________
How confident am I that I can achieve this goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 29
Week 7 – My Exercise Diary
Day Date
Monday / /
Tuesday / /
Wednesday / /
Thursday / /
Friday / /
Saturday / /
Sunday / /
Moderate flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Severe flare up? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
If you answer ‘yes’, please follow the instructions on page 5.
My endurance exercises Type:______________________
Duration: (goal)______________
Steps/distance: (goal)_________
Breathing score: (goal)________
Leg score: (goal)_____________
My strengthening exercises 1.
2.
3.
4.
5.
Comments
HomeBase – Last reviewed October 2017 30
HomeBase – Last reviewed October 2017 31
Week 7 – My Exercise Goals
My exercise goal for this week is:________________________________________________________
When I will do my exercise:_____________________________________________________________
Where I will do my exercise:_____________________________________________________________
How often I will do my exercise:__________________________________________________________
What might get in the way of my plan:_____________________________________________________
What I can do about it:__________________________________________________________________
How confident am I that I can achieve my exercise goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
Week 7 – My Health Goals
HomeBase – Last reviewed October 2017 32
One way I want to improve my health is:_________________________________________________
My health goal for this week is: ________________________________________________________
When I will do it:_____________________________________________________________________
Where I will do it:____________________________________________________________________
How often I will do it:_________________________________________________________________
What might get in the way of my plan:____________________________________________________
What I can do about it:_________________________________________________________________
How confident am I that I can achieve this goal (please circle one):
Not at all confident
A little confident
Somewhat confident
Very sure
Totally confident
HomeBase – Last reviewed October 2017 33
Week 8 – My Exercise Diary
Day Date
Monday / /
Tuesday / /
Wednesday / /
Thursday / /
Friday / /
Saturday / /
Sunday / /
Moderate flare up? Yes No Yes No Yes No Yes No Yes No
Yes No
Yes No
Severe flare up? Yes No Yes No Yes No Yes No Yes No
Yes No
Yes No
If you answer ‘yes’, please follow the instructions on page 5.
My endurance exercises Type:______________________
Duration: (goal)______________
Steps/distance: (goal)_________
Breathing score: (goal)________
Leg score: (goal)_____________
My strengthening exercises 1.
2.
3.
4.
5.
Comments
HomeBase – Last reviewed October 2017 34
HomeBase – Last reviewed October 2017 35
Improving your health There are steps you can take to control the symptoms of COPD and slow down the progressive damage to your lungs. Your health care professionals can help you to take steps that will make you feel better. Each week, you will have the opportunity to discuss one of these areas during your phone call with the health professional. Areas that you might like to discuss include:
• Exercising for better health • Understanding your medications • Maintaining a healthy diet
• Losing or gaining weight • Managing breathlessness • Managing flare-ups and chest infections • Quitting smoking • Making the most of your health professionals • Getting the right support
In this space you might like to write down other topics you would like to discuss with the health professional: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
HomeBase – Last reviewed October 2017 36
Who can I contact if I have questions or need assistance?
For further information concerning your pulmonary rehabilitation program, or if
you have any concerns, you can contact:
Name:_______________________________________________________________________
Ph:___________________________________________________________________________
Name:________________________________________________________________________
Ph:____________________________________________________________________________