CURRENT:
Appendix 4
| Health-care provider guidelines | ||||
| Suggest step count increments at each clinic visit to reach goal (an increase of 3,000 steps per day above the baseline step count within 1 year). | ||||
| Steps per day at baseline | Clinic visit 1 (0 months) | Clinic visit 2 (3 months) | Clinic visit 3 (6 months) | Clinic visit 4 (9 months) |
| <5,000 | +500 | +750 | +750 | +1,000 |
| 5,000-7,499 | +750 | +1,000 | +1,250 | |
| ≥7,500 | +1,000/+2,000 | +1,000 | ||
| Start Date: | ||||
| Patient's Name: | ||||
| Baseline Step Count: Clinic Visit Number: | Recommended Step Count: Start Date for Step Increase: | |||
| Patient step count prescription | ||||
| Today's Date: | ||||
| Patient's Name: | ||||
| • Please try to complete at least _________ steps per day until your next visit. • Please record your step counts in your log sheets at the end of each day. • Please bring your log sheets to the next clinic visit which will be in about three months. | ||||
| Physician's Name: | ||||
| Physician's Signature: | ||||