Healthy Changes: Setting Goals & Making Plans
Is there one thing that you would like to change that would help you be healthier? This is a work sheet you may use to help you decide about making a healthy change. You may use it by yourself or with a family member or friend. Below is a list of some things that people often want to change. There are also some spaces to write in other topics important to you.
Change can be hard. Depending on how big a change or how many changes you want to make, you may have one goal or a number of goals to reach. Don’t try to reach all of your goals at once. Make a plan to help you take things step by step. And be proud of each step you take and each goal you reach.
My Choice for a Healthy Change
The change I want to make is: __________________________________________________
Please circle the number below that shows how important it is to you to make this change:
Not important Very important
1 2 3 4 5 6 7 8 9 10
My Goal and Plan for a Healthy Change
It is easier to make a change when you set a goal and make a plan to reach it.
Please fill in the blanks below and share your answers with your health care team.
This is my goal for next week or month (circle one): ____________________
This is what I will do to reach my goal:
How much: _____________________________________________
How often: _____________________________________________
These things may make it hard to reach my goal: ___________________
This is how I will deal with these things: ___________________________
These are the resources and support I will need to reach my goal: _____
Please circle the number below that shows how sure you are (confident)
that you can reach your goal:
Not sure Very sure
1 2 3 4 5 6 7 8 9 10
You are more likely to reach your goal when your confidence level is a 7 or more.
If you chose a number below 7, think about ways to change your goal or plan so you feel more sure that your plan will work and you will reach your goal.
I will follow-up with ________________________
How-phone, email,in-person, other
Date & Time
The information provided should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Any duplication or distribution of the information contained herein is strictly prohibited.
Last Updated: 07/10/2013
Copyright © 07/09/2013 University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#7523
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