My Plan & Goals

How are you doing with your weight? (Exercise, eating, taking care of yourself)
 Excellent  Good  Not Good  Not Sure

I am doing well with: I want to do better with:

 Exercising & moving more  Exercising & moving more

 My mood & mental health  My mood & depression

 Eating 5 fruits & veggies a day  Eating 5 fruits & veggies a day

 Limiting TV & computer time  Limiting TV & computer time

 Drinking less sugar  Drinking less sugar

 Managing my stress  Managing my stress

 Avoiding alcohol, tobacco & drugs  Avoiding alcohol, tobacco & drugs

 Sleeping well  Sleeping well

 Cutting down on junk & fast food  Cutting down on junk & fast food

 Remembering 7-5-2-1-0  Remembering 7-5-2-1-0

 Managing other health problems  Managing other health problems

(Diabetes, high blood pressure, asthma, etc) (Diabetes, high blood pressure, asthma, etc)

 Other: _________________________  Other: ________________________

To improve my health, I will work on one of the activities I checked above

I will do:
How much or often:
When:
On a scale of 0 – 10, how willing/important is it to you to make a change toward a healthier lifestyle?
0 — 1 — 2 — 3 — 4 — 5 — 6 — 7 — 8 — 9 — 10
Not willing/Not Important Somewhat Very Willing/Very Important

On a scale of 0 – 10, how confident are you that you can succeed?
0 — 1 — 2 — 3 — 4 — 5 — 6 — 7 — 8 — 9 — 10
Not willing/Not
Adopted Important
from: “My Diabetes Plan” by The California Academy of Family Somewhat
Physicians Very Willing/Very Important