Gateshead Hea

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Signposting you t
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AlCOHOL Physical Activity

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Personal Action Plan

• I have explained the health trainer service to the client.
• I have explained that patient information will be entered into a database and will
be securely stored in accordance with the Data Protection Act and NHS Guidance.

The following information has been provided:

Signed:

Name: Date:

Job Title: Health Trainer

Supporting the NHS Health Trainer programme

 My Action Plan How will I work towards achieving my goal?

My Goal is:

How confident do I feel about my goal?

Who can help? What services, groups or organisations are out there?
0 1 2 3 4 5 6 7 8 9 10
Not Very
confident confident

Wellbeing Measure When can I make time to work on my goal?

Self-efficacy (tick which applies to you)

Section to be completed before the personal health plan.
What barriers are in my way?
1. I will be able to achieve most of the goals I set for myself.
Strongly Disagree Not Sure Agree Strongly
disagree agree

2. When facing difficult tasks, I am certain that I will succeed.

Strongly Disagree Not Sure Agree Strongly
disagree agree How might I overcome existing barriers?
3. In general, I think I can achieve outcomes that are important to me.
Strongly Disagree Not Sure Agree Strongly
disagree agree

4. I believe I can succeed at most tasks to which I set my mind.

Strongly Disagree Not Sure Agree Strongly
disagree agree Who might help?

5. I will be able to successfully overcome many challenges.

Strongly Disagree Not Sure Agree Strongly
disagree agree
When I am successful, I will feel…
6. I am confident that I can manage well on many different tasks
Strongly Disagree Not Sure Agree Strongly
disagree agree

7. Compared to other people, I can do most tasks very well.

Strongly Disagree Not Sure Agree Strongly
disagree agree My Health Trainer is:

8. Even when things are tough, I can manage quite well. I can ring them for help and advice on:
Strongly Disagree Not Sure Agree Strongly
disagree agree
4 Week Review Date:

2 3
 Daily Diary Daily Diary

I can use this space to write how my days have been. What has gone well Week Beginning:
and what hasn’t gone well, what barriers have I come across and which
services and people have helped.
Monday
Week Beginning:

Monday
Tuesday

Tuesday
Wednesday

Wednesday
Thursday

Thursday
Friday

Friday
Saturday

Saturday
Sunday

Sunday Alcohol
Know you units – It is recommended that men drink no more than 3-4
units per day and women 2-3.
Physical Activity
Did you know? – It is recommended you do 30 minutes of moderate choices
activity such as walking or general household chores such as vacuuming www.nhs.uk/choices
and ironing per day. Apply for an Active Access Card if you are in receipt
of selected benefits. Visit www.gateshead.gov.uk

4 5
Daily Diary Daily Diary

Week Beginning: Week Beginning:

Monday Monday

Tuesday Tuesday

Wednesday Wednesday

Thursday Thursday

Friday Friday

Saturday Saturday

Sunday Sunday

For advice on cholesterol and diet visit:

www.bhf.org.uk
tel: 0207554 0000 For further information on a healthy lifestyle visit:
Heart Helpline: 0300 330 3311 www.nhs.co.uk/change4life

6 7
 4 Week Review - Wellbeing Measure (after)

Self-efficacy (tick which applies to you)

Section to be completed after the personal health plan.

9. I will be able to achieve most of the goals I set for myself.

Strongly Disagree Not Sure Agree Strongly
disagree agree

10. When facing difficult tasks, I am certain that I will succeed.

Strongly Disagree Not Sure Agree Strongly
disagree agree

11. In general, I think I can achieve outcomes that are important to me.
Strongly Disagree Not Sure Agree Strongly
disagree agree

12. I believe I can succeed at most tasks to which I set my mind.

Strongly Disagree Not Sure Agree Strongly
disagree agree

13. I will be able to successfully overcome many challenges.

Strongly Disagree Not Sure Agree Strongly
disagree agree

14. I am confident that I can manage well on many different tasks

Strongly Disagree Not Sure Agree Strongly
disagree agree

15. Compared to other people, I can do most tasks very well.

Strongly Disagree Not Sure Agree Strongly
disagree agree

16. Even when things are tough, I can manage quite well.
Strongly Disagree Not Sure Agree Strongly
disagree agree

Notes: