Professional Documents
Culture Documents
Instructions:
Indicate which response most accurately describes your stage of change for two different
behaviors (in the blank space identify the behavior: physical activity, weight control,
nutrition, stress, smoking).
Next, select the statement (select only one) that best represents your current behavior pattern.
To select the most appropriate statement, fill in the blank for one of the statements if your
current behavior is a problem behavior. (For example, you might say, “I currently smoke and I
do not intend to change in the foreseeable future.” or “I currently do not exercise but I am
contemplating changing in the next 6 months.”
If you have already started to make changes, fill in the blank in one of the last two statements.
(In this case, you might say: “I currently eat a low-fat diet but I have done so only within the last
6 months,” or “I currently practice adequate stress management techniques and I have done so
for more than 6 months.”) You may use this technique to identify your stage of change for any
type of health-related behavior.
Example 1:
In the blank space identify the behavior which response most accurately describes your stage of
change, (e.g., physical activity, weight control, nutrition, stress, smoking.
Select one of the following statements that best represents your current behavior pattern.
Specific goal and date to be accomplished: _Daily routine for cardiorespiratory endurance
exercise
Example 2:
In the blank space identify the behavior which response most accurately describes your stage of
change, (e.g., physical activity, weight control, nutrition, stress, smoking.
Behavior 2: _Nutrition__
Select one of the following statements that best represents your current behavior pattern.
4. I currently _____________________, but I have done so only within the last 6 months.
Specific goal and date to be accomplished: To rely on a meal not always on the fast-food chain
but to consider food preparation specially fruits & vegetable included for meal at home.
Stages of Change
1 = Precontemplation 4 = Action
2 = Contemplation 5 = Maintenance
3 = Preparation 6 = Termination/Adoption
Now, it’s your turn!
In the blank space identify the behavior which response most accurately describes your stage of
change, (e.g., physical activity, weight control, nutrition, stress, smoking.
Behavior 1: _________________
Select one of the following statements that best represents your current behavior pattern.
1. I currently _____________________, and I do not intend to change in the foreseeable future.
2. I currently _____________________, but I am contemplating changing in the next 6 months.
3. I currently _____________________, regularly but intend to change in the next month.
4. I currently _____________________, but I have done so only within the last 6 months.
5. I currently _____________________, and I have done so for more than 6 months.
And fill in the blank to complete the statement.
____________________________________________________________________________
____________________________________________________________________________
_________________________________________________
In the blank space identify the behavior which response most accurately describes your stage of
change, (e.g., physical activity, weight control, nutrition, stress, smoking.
Behavior 2: _________________
Select one of the following statements that best represents your current behavior pattern.
1. I currently _____________________, and I do not intend to change in the foreseeable future.
2. I currently _____________________, but I am contemplating changing in the next 6 months.
3. I currently _____________________, regularly but intend to change in the next month.
4. I currently _____________________, but I have done so only within the last 6 months.
5. I currently _____________________, and I have done so for more than 6 months.
And fill in the blank to complete the statement.
____________________________________________________________________________
____________________________________________________________________________
_______________________________________________
Sample SMART goal: By the end of the month, I will be walking 20 minutes per day, three times a week.
Find a walking partner. Friend is busy Walk with mp3 player during solo walks
Schedule this after my class Study for an exam Start studying for an exam days before
the date
Specific: ___________________________________________
Measurable: ____________________________________________
Attainable: ____________________________________________
Realistic: ____________________________________________
Time-specific: ____________________________________________
SMART goal: