Goal: ____________________________________________________

Domain: ______________________
Action Plan:

Month: __________________

______________________________________ (what)
______________________________________ (how much)
______________________________________ (when)
______________________________________ (how many)

Intentional Activity

Date

How
Much

Number of Members
Who Participated

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Note: Group physical activities must be chosen by the participants and can include walking, active Wii games, lawn
games, stretching, yoga, and dancing, but do not include pool.

Goal: ____________________________________________________
Domain: ______________________

Month: __________________

In writing your action plan, be sure it includes:

1. What you are going to do;
2. How much you are going to do;
3. When you are going to do it; and
4. How many days a week you are going to do it.
For example: This month, we will walk (what) around the block (how much) before lunch (when)
one time per week (how many).

This month we will

__________________________________ (what)
__________________________________ (how much)
__________________________________ (when)
__________________________________ (how many)

How confident are you? (0 = not at all confident; 10 =

totally confident) ______