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Healthy Behavior Goal Plan
This Goal Plan/Contract takes about 5-minutes to complete.
1.
What is today's date (month/day/year)?
(Required.)
2.
First Name (Optional)
3.
Are you...
(Required.)
Male
Female
Other
4.
How old are you?
(Required.)
9 years old or younger
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
19 years old
20 years old
21 years old
22 years old
23 years old
24 years old
25 years old or older
5.
Which of the following do you pledge to avoid or reduce during the next 7 days in order to maintain an active and healthy lifestyle?
(Required.)
Alcohol
Tobacco
E-cigarettes
Marijuana
Non-medical opioids
Other illegal drugs
6.
Which
one
of the following healthy habits will you focus on improving during the next 7 days.
(Required.)
Get 8 or more hours sleep each night
Eat a healthy breakfast every day or eat a daily variety of other healthy foods such as fresh fruits and vegetables
Participate in some fun physical activity or sports 30-60 minutes most days a week
Practice a stress control technique most days a week like yoga, meditation, prayer or walking in nature.
Other (please specify)
7.
From the healthy habit you identified, now write a
specific, measurable and attainable healthy habit goal
you will achieve over the next 7 days. For example, playing tennis is measurable but getting more exercise is not, and eating more fruits and vegetables is measurable but eating healthier is not.
(Required.)
8.
Now, write an
exact amount (quantity) of that one habit
you just listed above which you will do each time you do it. For example, 30 minutes each time you play tennis, or 1 more serving of fruits and vegetables each day.
(Required.)
9.
List an exact frequency of that same habit
you will do during the next week. For example, 4 days a week, Monday-Thursday, or each day of the week.
(Required.)
10.
List where
you will engage in the healthy behavior. (Specific location).
11.
List with whom
you will engage in the healthy behavior. (For example, a friend, family member, alone):
12.
Who will you share your goal with? Sharing your goal will increase your motivation to follow through with your plan.
(Required.)
Teacher
Mom or dad
Grandmother or grandfather
Aunt or uncle
Older brother or sister
Trusted and supportive friend
Other (please specify)
13.
Where will you post your goal plan so you can see it every day and be reminded to monitor your health habits? Choose one.
(Required.)
Bedroom wall or mirror
Bathroom mirror
Refrigerator door
TV or computer
Other (please specify)
14.
Congratulations!
You have successfully completed a Prevention Plus Wellness program goal plan.
· Don't forget to print out and post your goal plan and attached calendar where you can see it every day and check-off each day you reach a goal.
· At the end of your 7-day goal plan return to this site and write another goal plan to continue to make small changes to feel and look better.
· Reward yourself with small things you enjoy like magazines, music, books, watching a movie, playing and instrument, or doing art, for achieving one of your wellness goals, or avoiding alcohol, tobacco, e-cigarettes or illegal drug use.
Now rate the goal plan on the 5-star scale below.
1 star
2 stars
3 stars
4 stars
5 stars
15.
After you print out this goal plan
, post and circle a response on the calendar below each day during the next 7 days to track your goal success. Then, total the number of days you reached a wellness goal.
Do NOT Answer This Now.
Day 1 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 2 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 3 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 4 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 5 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 6 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 7 Goal Success: 1: Yes 2: No 3: No goal set for today
Week's Total Success Days (Number of "Yeses" Above) =
16.
Now, PRINT OUT your goal plan and calendar and post them so you’ll see them every day for the next 7 days.
