Healthy Behavior Goal Plan

This Goal Plan/Contract takes about 5-minutes to complete.

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

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2. First Name (Optional)

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3. Are you...

Male

Female

Other

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4. How old are you?

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

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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?

Alcohol

Tobacco

E-cigarettes

Marijuana

Non-medical opioids

Other illegal drugs

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

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)

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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. 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. List where you will engage in the healthy behavior. (Specific location).

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11. List with whom you will engage in the healthy behavior. (For example, a friend, family member, alone):

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12. Who will you share your goal with? Sharing your goal will increase your motivation to follow through with your plan.

Teacher

Mom or dad

Grandmother or grandfather

Aunt or uncle

Older brother or sister

Trusted and supportive friend

Other (please specify)

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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.

Bedroom wall or mirror

Bathroom mirror

Refrigerator door

TV or computer

Other (please specify)

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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.

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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) =

Healthy Behavior Goal Plan

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

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2. First Name (Optional)

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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 or reduce 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 will you focus on improving during the next 7 days.

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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. 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. List where you will engage in the healthy behavior. (Specific location).

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11. List with whom you will engage in the healthy behavior. (For example, a friend, family member, alone):

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12. Who will you share your goal with? Sharing your goal will increase your motivation to follow through with your plan.

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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.

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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.

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16. Now, PRINT OUT your goal plan and calendar and post them so you’ll see them every day for the next 7 days.