Appendix 4

Smarter Step Count Prescription

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:

Click to view printable and saveable pdf

*The Canadian Diabetes Association is the registered owner of the name Diabetes Canada. All content on, CPG Apps and in our online store remains exactly the same. For questions, contact