Version 2/7/12
for Walking with Pedometer
Graduated Rx (gradual increase over time)
for walking with your pedometer
NAME ________________________________________ DATE ___________________
Amount per week:
Week 1:
_____ steps
in ___ minutes
___ days per week
Week 2:
_____ steps
in ___ minutes
___ days per week
Week 3:
_____ steps
in ___ minutes
___ days per week
After Week 3:
_____ steps
in ___ minutes
___ days per week
Other instructions: ____________________________________________________
_____________________________
Patient’s signature
_____________________________
Provider’s signature
Developed by: Linda S. Gottfredson, PhD, School of Education, University of Delaware, & Kathy Stroh, MS, RD, CDE,
Diabetes Prevention and Control Program, Delaware Division of Public Health (Dec 2008; Rev. Feb 2012)
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