Patient: Age: Weight:

Goal Planner


Function Goals

Completed by:
Patient or Clinician

Remember, a good goal needs to be "SMARTER"

Specific, Small steps
Measurable and Meaningful
Action/Achievable
Realistic (accepting that pain will be included),
Time based and Tracking (writing it down)
Evaluate (weekly) and Enthusiasm (self-talk)
Reward and/or Reset

1. What is the goal:


2. How important is the goal?
0 1 2 3 4 5 6 7 8 9 10
Not At AllCompletely

3. How confident you can achieve the goal?
0 1 2 3 4 5 6 7 8 9 10
Not At AllCompletely

4. Barriers to achieving goal:


5. Solutions to achieving goal:

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