This Goal Contract takes 5-minutes to complete.

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* 1. What is today's date (month/day/year)?

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* 2. First and Last Name

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* 3. Are you...

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* 4. How old are you?

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* 5. Which of the following do you pledge to avoid using during the next 7 days in order to maintain an active and healthy lifestyle?

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* 6. Which one of the following healthy habits you will focus on improving during the next 7 days.

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* 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. 

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* 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. 

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* 9. Last, 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. 

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* 10. In addition to yourself, who else will sign this goal plan to make it an official contract between you and them?

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* 11. Where will you post your goal plan/contract so you can see it every day and be reminded to monitor your health habits?  Choose one.

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* 12. Congratulations!  You have successfully completed a Prevention Plus Wellness program follow-up goal plan.  


·      Print out a copy of your goal plan so you can sign and date it and have the person you identified co-sign it.    

·      Don't forget to post your goal plan 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.

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* 13. After you print out this goal plan, 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. 

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* 14. After you print it out, sign and date your goal plan.

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* 15. After you print it out, have the person you identified above co-sign and date your goal plan.

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