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PERSONAL WELLNESS PLAN ENTRY FORM

Instructions on completing this form:

Goal # 1 is associated with Payoff #1 and Goal Supportive Activities #1 etc. and is 1 month in duration.

Goal # 2 is associated with Payoff #2 and Goal Supportive Activities #2 etc. and is 6 months in duration.

Goal # 3 is associated with Payoff #3 and Goal Supportive Activities #3 etc. and is 1 year in duration.

*** Note: This form should be completed with information
relating to your most recent fitness exam report.
If you have not had a fitness exam in the last 1 month,
please contact our office to schedule your fitness exam
prior to completing the form. Please call 281-332-1111

Personal Wellness Plan For
GOAL(Make it specific, measurable, positive, and within a timeframe)
1.
2.
3.

Payoffs (which I will realize by fulfilling my goal)
1.
2.
3.

Goal Supportive Activities(note specific measures and activities and when they will be performed. A chart or journal may be helpful for monitoring progress)
1.
2.
3.

Barrier Busters(I might sabotage my plan by... so I plan to overcome this by...)
1.
2.
3.

Mini-Goals & Rewards(times to measure and reinforce my progress my plan if necessary)
1.
2.
3.

Support Group(signatures of friends who will help with my plan at least once this week)
1.
2.
3.

Comments


My pledge: I will accomplish this goal. Bet on it! I agree to it. I want it, I am going about it in a methodical way, and it is going to happen!

Take a closer looK... Use a journal or log to keep track of the lifestyle change you are about to make. Doing this will enable you to plan for the situations and feelings that may hinder your progress.