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Lifestyle Goal Worksheet |
Name:
Date:
Wellness Vision
Activity and Exercise
My intermediate activity and exercise goals:
A
B
C
How I plan to get there:
To increase my lifestyle activity by ____ minutes per day I will:
To increase my structured activity I will:
minutes times per week
minutes times per week
minutes times per week
minutes times per week
Weight and Eating Habits:
My target weight is:
In 4 weeks I would like to weigh:
In 8 weeks I would like to weigh:
In 12 weeks I would like to weigh:
To eat healthier and achieve a more reasonable weight I will:
Add When
Add When
Add When
Add When
Add When
Substitute for
Substitute for
Substitute for
Substitute for
Substitute for
Limit to
Limit to
Limit to
Limit to
Stress Busters
My overall level of stress is
1 2 3 4 5 6 7 8 9
Minimal Maximal
To better manage stress I can:
A when
B when
C when
Counseling support
I plan to meet with my Lifestyle and weight management consultant
individually times per month
group times per month
Anticipated absences:
Other people I can ask for support:
Who? Can help how?
Who? Can help how?
Who? Can help how?
Who? Can help how?
Who? Can help how?
Additional Goals (sleep, smoking, etc.)
when
when
when
when
when
when
when
Potential Obstacles and Solutions
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Obstacle |
Solution |
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Evaluation of Goals
We plan to evaluate
these goals in weeks on
Client
Lifestyle and Weight Management Consultant; Elizabeth Sherman
Attainment of Goals
Goals achieved
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Date |
Goal |
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Additional Goals