Patient Home Program Instructions (Biofeedback Therapy)

Home Biofeedback Practice Instructions

Patient Name: [Patient name]

Date of Birth: [DOB]

Date: [Date]

Provider: [Provider name, credentials, clinic/facility]

Questions? Call: [Clinic phone number]

What This Is For

[Purpose of home practice and training focus] [Target symptoms or functional goals] (Write 2–3 short sentences in plain language. State how often to review these instructions. Do not include diagnostic labels unless explicitly appropriate for patient-facing display.)

[Patient-stated goal quote] (Include only if documented; one short sentence in quotes.)

Safety: When to Stop

Stop and call the clinic: [Clinic phone number]

• Worsening of your target symptoms that does not settle after practice adjustments.
• New pain or unexpected symptoms related to the training area.
• Device issues that cause discomfort or skin irritation. (Include only if device is used.)
• Inability to perform the technique as instructed.

[Condition-specific precautions] (Include only if applicable to this patient's assigned program, e.g., slow breathing pace if lightheaded. Omit entirely if no special precautions apply.)

Your Practice Plan

(Only include rows with complete dosing details. Omit any exercise where dose is not finalized.)

Skill/Exercise	When	Duration	Frequency	Target/Notes
[Exercise name]	[Time of day or trigger]	[Minutes or reps]	[Times/day, days/week]	[Position, intensity cue, device target]

How To Practice

(For each exercise above, include 4–6 numbered steps with action words and simple sensory cues. Include one common mistake and fix.)

[Exercise name]

1. [Step with body position or breath cue]
2. [Step with timing or pacing cue]
3. [Step with sensory focus cue]
4. [Step with feedback cue] (If device used.)
5. [Close-out cue]

• Common mistake: [Mistake]. Fix: [Correction].

Progression

[Progression rules: when to increase, when to hold steady, maximum dose] (Include only if prescribed. Omit section entirely if no progression rules apply.)

Device Instructions

(Include this section only if a home device or app is prescribed. If setup training has not occurred, include only the sentence below and omit the bullets.)

Device setup—training required at next visit. (Only if training not yet completed.)

• Device: [Device name/model]
• Targets/settings: [Prescribed targets in plain language]
• Care: [Cleaning and storage steps]

Tracking Your Practice

Record each practice session:

• Date
• Exercise practiced
• Duration
• Symptoms before and after (0–10)
• Notes (triggers, stress level, relevant symptoms)

How to submit: [paper diary / portal upload / bring device report]

Logging frequency: [Expected frequency and when to share]

Follow-Up

[Next appointment date/time/location] (Include if scheduled; otherwise provide scheduling instructions.)

• Bring your practice log.
• Bring your device and supplies. (If applicable.)
• Your provider will review your log and adjust your plan.

Important: Do not change or stop prescribed medicines without speaking to your prescribing clinician. This program is not for emergency care—call 911 for emergencies.