My Blood Pressure Action Plan And Follow-Up Care Form printable pdf download

My Blood Pressure Action Plan And Follow-Up Care Form

My Blood Pressure

Action Plan and

Follow-up Care

Form

Bring this form to your next

doctor visit. Together, you

and your physician can create

a personal blood pressure

goal and develop a plan to

achieve it.

My blood pressure was

_________/_________ on ___/___/___

Systolic

Diastolic

Date

My Blood Pressure GOAL:

_________/_________

Systolic

Diastolic

Weight Reduction

Losing just a little weight can make big changes in blood pressure.

Current Weight: ____________________ Goal Weight: ________________________

Steps I will take to achieve my goal:

___________________________________________________________________________________

Exercise/Activity Planning

Every little bit of exercise helps my heart stay healthy. I will make a goal to keep physically active every day.

Steps I will take to achieve my goal:

___________________________________________________________________________________

My Blood Pressure Action Plan And Follow-Up Care Form