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:

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