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
Elicits Spectrum of Concerns
Negotiates Priorities and Sets Agenda
Organization
Pacing of Interview
Types of Questions
Summarizing
Lack of Jargon
Verification of Patient Information
Verbal Facilitation Skills
Non-Verbal Facilitation Skills
Empathy and Acknowledging Patient Cues
Patient's Perspective (Beliefs)
Impact of Illness on Patient and Patients Self-Image
Support Systems
Patient's Education and Understanding
Assess Motivation for Changes
Achieve a Shared Plan
Encouragement of Questions
Closure