My Goal Chart

The patient has stadium IIB of cervical cancer and has undergone chemotherapy and external radiation
MY GOAL CHART
We will talk you through this, but before we start we really need to know what you’d like to achieve by doing the program.
It can take a bit of time and thought, but it’s important for your motivation to do the program. See Chapter 8 (Setting
Goals) of Manage Your Pain.
MY GOALS Changes I can make over next 5 weeks At the end of

(What I want to achieve – be specific – (Things I need to do/work on to achieve program, rate
and say by when) my goals) extent to which I
Example “Prepare a meal at least 3 times a “Increase my standing tolerance (to 15 achieved this goal
week, within 2 months” minutes)” (0-100%)
Home tasks or
Eat and take a bath by myself Increase my standing tolerance to 30
activities
minutes
Read a book at least once a week Try to read a few pages every day
Paid work/study/ within three months
voluntary work
Family activities/ Accompany my children while they’re Increase my sitting tolerance to 1 hour
relationships doing their homework at least 5 times
a week within 3 months
Go to church every week within 3 Gain more energy to get fit (by eating and
Social activities months exercising regularly)
Recreation/sport/  Watch the TV for at least 1 hour Increase my sitting and walking tolerance
hobbies everyday within 3 months
 Walk inside and around the house
for 30 minutes at least 2 times a
week within 3 months
Take my medicines regularly as Set alarm to remind me to take my

Medication advised by doctor medicine on time
Sleep Take a nap for 1 hour during the day Practice deep breathing exercise before
and sleep for at least 6 hour during the sleeping
night within 3 months
Other?
WEEKLY HOMEWORK TASKS

At each session with our team, we will reach agreement with you on your homework tasks for the next
week (or two). We have found it helps to have a convenient place to record your tasks for each week.
This makes them easier to remember and provides a quick check on your progress through the
program.
Homework from the pain team
Week One  Eat routinely as advised Achieved?

 Deep breathing exercise daily
 Pacing my sitting, standing, walking
 Checking my charts at the end of the day
Week Two  Eat routinely as advised Achieved?


Week  Eat routinely as advised Achieved?

Three  Deep breathing exercise daily
Week Four  Eat routinely as advised Achieved?

MY ACTIVITY TOLERANCE CHART – USING PACING

Work only on the activities that you want to change (tick when goal achieved each day)
Sitting Standin Walking Carrying Lifting Reaching Climbing Key Deep Reading a
g breat book
Boar hing
d exerc
(time)
(time) (time ise
)
Dist Tim Wt Dist Wt Describe Fwd O’hea Step Ladde Time Page Time
e task d s r s
A
Estimate 30 minutes 20 50 10 bottl 50 500 To lift Reach Uprigh 10 10 p 20
what you minutes meter min e of m gr somethin forwar t hand minut minut
can do now s wate g from a d 15 positio es es
r
certain times n 15
(100
0 cc) position a day times
to a a day
higher
position
Baseline 25 minutes 18 30 m 8 500 30 250 From the 10 10 5 5p 10

(less than minutes min cc m gr couch times times minut minut
estimate (50 cm) es es
above) to the on
top of the
table (85
cm)
Goa
DAY Goal Goal Goal Goal Goal
l
Goal Goal Goal Goal Goal Goal Goal Goal Goal
1 25 minutes 18 30 m 8 500 30 250 10x 10x 5 5 10

minutes min
(Baseline)
25 minutes 18 30 m 8 500 30 250 10x 10x 5 5 10
2 minutes min
25 minutes 18 30 m 8 500 30 250 10x 10x 5 5 10
3 minutes min
27 minutes 20 40 m 8 550 40 300 12x 12x 7 5 10
4 minutes min
27 minutes 20 40 m 8 550 40 300 12x 12x 7 7 14
5 minutes min
27 minutes 20 40 m 8 550 40 300 12x 12x 7 7 14
6 minutes min
30 minutes 22 50 m 9 600 50 350 15x 15x 10 7 14
7 minutes min
30 minutes 22 50 m 9 600 50 350 15x 15x 10 10 20
8 minutes min
30 minutes 22 50 m 9 600 50 350 15x 15x 10 10 20
9 minutes min
32 minutes 24 60 m 9 650 60 400 17x 17x 12 10 20
10 minutes min
32 minutes 24 60 m 9 650 60 400 17x 17x 12 12 24
11 minutes min
Key
Sitting Standin Walking Carrying Lifting Reaching Climbing Deep Reading a
g Boar breat book
(time) d hing
(time) (time exerc
) ise
(Time
)
Dist Time Wt Dist Wt Describ Fwd O’hea Step Ladd Page Times
e d s er s
DAY Goal Goal Goal Goal Goal Goal Goal Goal Goal Goal Goal Goal Goal Goal Goal Goal
32 minutes 24 60 9 650 60 400 17x 17x 12 12 24
12 minutes min gr
34 minutes 26 60 10 650 60 450 17x 17x 15 12 24
13 minutes min
34 minutes 26 70 10 700 70 450 20x 20x 15 14 28
14 minutes min
34 minutes 26 70 10 700 70 450 20x 20x 15 14 28
15 minutes min
36 minutes 28 70 10 700 70 500 20x 20x 17 14 28
16 minutes min
36 minutes 28 80 10 750 80 500 22x 22x 17 16 32
17 minutes min
36 minutes 28 80 10 750 80 500 22x 22x 17 16 32
18 minutes min
38 minutes 30 80 11 750 80 550 22x 22x 20 16 32
19 minutes min
38 minutes 30 90 11 800 90 550 25x 25x 20 18 36
20 minutes min
40 minutes 32 90 11 800 90 600 25x 25x 20 18 36
21 minutes min
40 minutes 32 90 11 800 90 600 25x 25x 22 18 36
22 minutes min
42 minutes 34 100 11 850 100 650 27x 27x 22 20 40
23 minutes min
42 minutes 34 100 11 850 100 650 27x 27x 22 20 40
24 minutes min
44 minutes 36 100 12 850 100 700 27x 27x 25 20 40
25 minutes min
44 minutes 36 110 12 900 110 700 30 30 25 22 44

26 minutes min
46 minutes 38 110 12 900 110 750 30 30 25 22 44
27 minutes min
46 minutes 38 110 12 950 110 750 30 30 27 22 44
28 minutes min
48 minutes 40 120 12 950 110 800 32 32 27 24 48
29 minutes min
Key
Sitting Standing Walking Carrying Lifting Reaching Climbing Deep Reading a
Boar breat book
(time) (time) d hing
(time) exerc
ise
Dist Time Wt Dist Wt Describ Fwd O’hea St Lad

e d ep der
s
G
DAY Goa
Goal Goal Goal Goal Goal Goal Goal Goal Goal Goal oa Goal Goal Goal Goal
l
l
50 40 120 12 1000 120 800 32 32 27 24 48
30 minutes minutes min
50 42 120 13 1000 120 850 32 32 30 24 48
52 42 130 13 1050 130 850 35 35 30 26 52
52 44 130 13 1050 130 900 35 35 30 26 52
54 44 130 13 1100 130 900 35 35 32 26 52
54 48 140 14 1100 140 950 37 37 32 28 56
56 48 140 14 1150 140 950 37 37 32 28 56
56 50 140 14 1150 140 1000 37 37 35 28 56
58 50 150 14 1200 150 1000 40 40 35 30 60
58 52 150 15 1200 150 1050 40 40 35 30 60
60 52 150 15 1250 150 1050 40 40 32 30 60

60 54 160 15 1250 160 1100 42 42 32 30 60
62 54 160 15 1300 160 1100 42 42 32 30 60
WEEKLY PLAN
Plan your days over the week. Try to spread tasks through the day and make times for breaks. Tick them when done
Mon Tue Wed Thu Fri Sat Sun

-Stretch -Stretch -Stretch -Stretch -Stretch -Stretch -Stretch
-Relaxation -Relaxation -Relaxation -Relaxation -Relaxation -Relaxation -Relaxation
-Breakfast -Breakfast -Breakfast -Breakfast -Breakfast -Breakfast -Breakfast
-Walk -Walk -Walk to -Walk -Walk -Walk to -Exercise
A around the around the nearby shop around the around the nearby shop -Take a bath
M house house -Exercise house house -Exercise
-Exercise -Exercise -Take a bath -Exercise -Exercise -Take a bath
-Take a bath -Take a bath -Take a bath -Take a bath
-Lunch -Lunch -Lunch -Lunch -Lunch -Lunch -Lunch

-Read book -Read book -Read book -Read book -Read book -Read book -Read book
-Take a nap -Take a nap -Take a nap -Take a nap -Take a nap -Take a nap -Take a nap
P -Sit and talk -Tidy up the -Sit and talk -Water the -Tidy up the -Sit and talk -Water the
M with bedroom with plants living room with plants
children -Take a bath children -Take a bath -Take a bath children -Take a bath
-Take a bath -Take a bath -Take a bath
-Dinner -Dinner -Dinner -Dinner -Dinner -Dinner -Dinner

N -Watch TV -Watch TV -Watch TV -Watch TV -Watch TV -Watch TV -Watch TV
i -Deep -Deep -Deep -Deep -Deep -Deep -Deep
g breathing breathing breathing breathing breathing breathing breathing
h exercise exercise exercise exercise exercise exercise exercise
t -Check plan -Check plan -Check plan -Check plan -Check plan -Check plan -Check plan

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The patient has stadium IIB of cervical cancer and has undergone chemotherapy and external radiation

MY GOALS Changes I can make over next 5 weeks At the end of

week within 3 months

Take my medicines regularly as Set alarm to remind me to take my

WEEKLY HOMEWORK TASKS

Week One  Eat routinely as advised Achieved?

Week Two  Eat routinely as advised Achieved?

 Pacing my sitting, standing, walking

Week  Eat routinely as advised Achieved?

Week Four  Eat routinely as advised Achieved?

MY ACTIVITY TOLERANCE CHART – USING PACING

Baseline 25 minutes 18 30 m 8 500 30 250 From the 10 10 5 5p 10

1 25 minutes 18 30 m 8 500 30 250 10x 10x 5 5 10

44 minutes 36 110 12 900 110 700 30 30 25 22 44

Dist Time Wt Dist Wt Describ Fwd O’hea St Lad

60 52 150 15 1250 150 1050 40 40 32 30 60

Mon Tue Wed Thu Fri Sat Sun

-Lunch -Lunch -Lunch -Lunch -Lunch -Lunch -Lunch

-Dinner -Dinner -Dinner -Dinner -Dinner -Dinner -Dinner

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