* 1. Name:

* 2. Age:

* 3. Email address:

* 4. Phone:

* 5. Weekly Log (1-13):

* 6. What is your goal this week (or for the span of the Healthy Lifestyle Challenge)?

* 7. Exercise:

  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Walking/Hiking
Weightlifting
Cardio
Outdoor Activity
Yoga
Sports
Miscellaneous

* 8. Nutrition:

  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Increased vegetable consumption
Increased fruit consumption
Adequate water consumption
Family meal together
Avoided or decreased sugar consumption
Avoided or decreased fast foods
Avoided or decreased fried foods
Avoided or decreased sodas and juice
Avoided or decreased alcohol use

* 9. Tobacco Cessation:

  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Avoided tobacco use
Decreased tobacco use

* 10. Stress Reduction:

  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Relaxation / meditation
Reading for pleasure
Other

* 11. Unplugged:

  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Replace 30 minutes of screen time (TV, electronic games, computer, phone) with a screen-free activity
Replace 30 minutes of headphone time (music, bluetooth) with a sound-free or low-sound activity

* 12. Doctors Visit:

  Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Get a physical
Get an eye exam
Dental check up
Mammogram
Other

* 13. Comments:

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