Pulmonary Rehabilitation Program Home Exercise Diary. Program contact:
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1 Pulmonary Rehabilitation Program Home Exercise Diary Program contact:
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
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
4 Hospital assessment: Date: Time: Location: 8 week assessment: Date: Time: Location: HomeBase Last reviewed October
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
6 Notes: HomeBase Last reviewed October
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 am I that I can achieve my exercise goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
8 HomeBase Last reviewed October
9 Day Date Monday Week 1 My Exercise Diary 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 Comments HomeBase Last reviewed October
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 am I that I can achieve my exercise goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
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 am I that I can achieve this goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
12 Day Date Monday Week 2 My Exercise Diary 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 Comments HomeBase Last reviewed October
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 am I that I can achieve my exercise goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
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 am I that I can achieve this goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
15 Day Date Monday Week 3 My Exercise Diary 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 My endurance exercises Type: Duration: (goal) Steps/distance: (goal) Breathing score: (goal) Leg score: (goal) My strengthening exercises Comments If you answer yes, please follow the instructions on page 5. HomeBase Last reviewed October
16 HomeBase Last reviewed October
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 am I that I can achieve my exercise goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
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 am I that I can achieve this goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
19 Day Date Monday Week 5 My Exercise Diary 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 My endurance exercises Type: Duration: (goal) Steps/distance: (goal) Breathing score: (goal) Leg score: (goal) My strengthening exercises Comments If you answer yes, please follow the instructions on page 5. HomeBase Last reviewed October
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 am I that I can achieve my exercise goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
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 am I that I can achieve this goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
22 Day Date Monday Week 5 My Exercise Diary 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 Comments HomeBase Last reviewed October
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 am I that I can achieve my exercise goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
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 am I that I can achieve this goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
25 Day Date Monday Week 6 My Exercise Diary 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 Comments HomeBase Last reviewed October
26 HomeBase Last reviewed October
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 am I that I can achieve my exercise goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
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 am I that I can achieve this goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
29 Day Date Monday Week 7 My Exercise Diary 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 My endurance exercises Type: Duration: (goal) Steps/distance: (goal) Breathing score: (goal) Leg score: (goal) My strengthening exercises Comments If you answer yes, please follow the instructions on page 5. HomeBase Last reviewed October
30 HomeBase Last reviewed October
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 am I that I can achieve my exercise goal (please circle one): Not at all A little Somewhat Very sure Totally Week 7 My Health Goals HomeBase Last reviewed October
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 am I that I can achieve this goal (please circle one): Not at all A little Somewhat Very sure Totally HomeBase Last reviewed October
33 Week 8 My Exercise Diary Day Date Monday Tuesday Wednesday Thursday Friday Moderate flare up? Yes No Yes No Yes No Yes No Yes No Severe flare up? 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 Saturday Yes No Yes No Sunday Yes No Yes No 5. Comments HomeBase Last reviewed October
34 HomeBase Last reviewed October
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
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: HomeBase Last reviewed October
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