EXERCISE COUNSELING SCORING FORM
First Name:
Last Name:
Student ID:
History Checklist
 CC: I'd like to start an exercise program
 Additional concern: I've been feeling tired over the past year
 Medical history: High cholesterol
 Surgical history: Back surgery after fall off horse in 1970
 Surgical history: C-Section for 3rd child in 1976
 Medications: Lipitor 20 mg QD
 Allergies: None
 Family History: Father died of heart attack at 81; Mother, 93, arthritis
 Exercise history: Active until age 25. Since then sporadically active
 Financial situation: Comfortable
 Insurance Situation: Has insurance through husband's work
 Sources of stress: Mother is 93 years old and lives in an assisted living facility
 Physical limitations: Occasional back pain
 Barriers: Back pain, intimidated by younger people at gym
 Support: Husband, daughter, and co-workers
Counseling Checklist
 Student summarized benefits of exercise and risks of inactivity
 Student addressed barriers to changing behavior
 Student addressed past attempts at behavior modification
 Student addressed pertinent family history
 Student made plan of action: calendar
 Student found out who would exercise with the patient
 Student emphazised working together
 Student Supplied solutions (start slowly, low impact, use personal trainer)
 Student asked patient to consider some contract for change
 Student suggests follow-up appointment
MIRS
Opening
select answer
1
2
3
4
5
Elicits Spectrum of Concerns
select answer
1
2
3
4
5
Negotiates Priorities and Sets Agenda
select answer
1
2
3
4
5
Organization
select answer
1
2
3
4
5
Pacing of Interview
select answer
1
2
3
4
5
Types of Questions
select answer
1
2
3
4
5
Summarizing
select answer
1
2
3
4
5
Lack of Jargon
select answer
1
2
3
4
5
Verification of Patient Information
select answer
1
2
3
4
5
Verbal Facilitation Skills
select answer
1
2
3
4
5
Non-Verbal Facilitation Skills
select answer
1
2
3
4
5
Empathy and Acknowledging Patient Cues
select answer
1
2
3
4
5
Patient's Perspective (Beliefs)
select answer
1
2
3
4
5
Impact of Illness on Patient and Patients Self-Image
select answer
1
2
3
4
5
Support Systems
select answer
1
2
3
4
5
Patient's Education and Understanding
select answer
1
2
3
4
5
Assess Motivation for Changes
select answer
1
2
3
4
5
Achieve a Shared Plan
select answer
1
2
3
4
5
Encouragement of Questions
select answer
1
2
3
4
5
Closure
select answer
1
2
3
4
5