Injuries Monitoring Form

(Only to be filled out for 2 days if you went bicycling outside)

Behaviour Goal 1: Wear a helmet while riding a bicycle.

Did you wear a bicycle helmet? My Goal Met?

Date Yes/No Yes/No

'I

(Only to be filled out for 2 days if you were a passenger on a motorcycle/ scooter/ two-
wheeler)

Behaviour Goal 2: Wear a helmet while riding a motorcycleLscooterLtwo-

wheeler.

Did you wear a helmet? My Goal Met?

-
Date Yes/No Yes/No

- -
- - --
 (Fill this for next 2 days)

Air Pollution Monitoring Form

Behaviour Goal 1: Wear Facemasks when the air pollution level outside is
high

Date AQI Level (PM Did you wear a My Goal Met

2.5) mask when you (Yes/ No)
went outside?
(Yes/No)
~ob

Dental Health Monitoring Form

Behaviour Goal 1: Brush teeth 11ro11erl~ at least twice a da~ and floss at least
once a da~.

Date How many times My Goal How many My Goal

did you brush your Met? times did you Met?
teeth? Yes/ No floss? Yes/ No
,g/.2I~) ,.i~ 0~
1~/il.w.:2 .1.,~ 0~ 'dt.A

I,
/I
 (Fill this for next 2 days)

Physical Activity Monitoring Form

Behavioural Goal 1: Do moderate to vigorous l!h~sical activit~ for at least

60 minutes eve!Jl da~

How many minutes of moderate or My Goal Met?

Date
vigorous physical activity did you do? (Yes/ No)

1s/u2IJ~3 30 ¼.
,q /a/1.o;i: 6V-7;5'~

Tobacco Monitoring Form

Behaviour Goal 1: Avoid second-hand smoke

Were you present for an extended

period of time in a room/ an enclosed
My Goal Met?
Date space where someone else was
(Yes/ No)
smoking?
(Yes, No, Not Applicable)

t"'~'~'..3 N&
1 /;; 1Jc). ,
1 %
 (Fill this for next 2 days)

Hygiene Monitoring Forms

•
Behaviour •
Goal 1: Cough or sneeze mto JlOUr s1eeve or cover JlO ur mouth/nose
- with a -
handkerchief

Did you cough or sneeze into your sleeve or cover

My Goal Met?
Date your mouth/nose with a handkerchief?
(Yes/ No)
(Always/ Sometimes/ Never/ Not Applicable)

18 /Uki,23 I\Lt,t

~12 /¾J).3 1\1.c-

Behaviour Goal 2: Wash Jlour hands ~ro~erlJl at least before eating a meal and after
going to the toilet.

My Goal
Did you wash your hands Did you wash your hands Met?
before eating a meal? after going to toilet? (Yes/ No)
Date
(Always/ Sometimes/ (Always/ Sometimes/ Write "Yes"
Never) Never) only if both
columns are
"Yes"
I(/ I; l-¾J~J A.J,., ,nA

19. /:J.. I :J.o~ ../1.I -~ ,l

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·~ "'.•.. Nutrition_MyPlate Monitoring form (Fill this for next 2 days)
Beh~viour Goal 1: Eat the required amount of foosi from each food group daily
Overall
Nutrition
Goal Goal
Goal Goal Met?
Goal Met Met
(Write
Date
Met
I
Goal: 5 portions of Fruits (5 or Goal: 3 portions of
Met
(3 or
Goal: 3 portions of
Protein
I (3 or Goal: 3 portions of dairy (3 or ''Yes" only
more products more
& Vegetables more Grains if all "Goal
more = =
=Yes) Met''
Yes) 'Yes)
Yes) columns are
Note: Fill in the number of portions you ate of each food group under B (Breakfast), L (Lunch), D (Dinner) and S (Snacks). Add and write the total of these under T (Total).
Y: Yes
N:~o.
(Fill this for next 2 days)
 ...~·
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Behavigur Goal 2: Eat a variety of foods within each food group daily
Date I
Did you eat a variety
offruits &
Did you eat a
variety of foods Did you eat a
I
My Goal met? (Write
"Yet' only if all three
vegetables? high In protein? variety of columns are "Yet')
Yes/ No Yes/No grains? Yes/ No
18~ ~
19~~
.. · "·{~~, , ;,. ..... t - •
I
Behaviour Goal 3: Limit foods and drinks high in added salt and sugar
What foods/ drinks did What foods/drinks did you
you consume that were My Goal consume that were high in My Goal How many My Sugar Goal Met?
Date
high in added salt? (if you met? added sugar? (If you did met? teaspoons of (Write "Yet' only If it Is
did not eat/ drink any, Yes/No not eat/ drink any, leave it Yes/No sugar did you "less than or equal to 6
leave it blank) blank_) _ _ consume? teaspooni')
)i3 JCM
-l"-
19f JQ.JV\ 2-
(Fill this for next 2 days)
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Behaviour Goal 4: Consume (onl~lthy snacks and drinks
Was It Healthy/ My Go.al Was it
Date Unhealthy? met? Healthy/ My Goal met?
What snacks did you Yes/No What drinks did you Unhealthy? Yes/ No
consume?
~ -·
consume? ...
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