2. What are the two to three biggest barriers to achieving these goals?

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1 Health Goals 1. Describe your major health, nutrition, and/or fitness goals: 2. What are the two to three biggest barriers to achieving these goals? What are the two to three greatest strengths that will help you to achieve these goals? Please check the box that best describes how ready you are to make changes to your lifestyle to achieve these goals Do not believe I need to change Would like to change, but don t think that I can Will make changes soon Recently started to make changes (past 6 months) Would like to intensify changes Made changes, but relapsed 5. On a scale of 1-10, how important is this change to you? 6. On a scale of 1-10, how confident are you that you will achieve this change? Health Information 7. How would you describe your health? Excellent Good Fair Poor Physical Activity 11. Are you currently physically active? 8. When was the last time you visited your physician? Nutrition History 9. Have you ever followed a modified diet to manage a health condition? If yes, please describe: 10. Do you follow a specialized diet (low carb, gluten-free, vegan, etc.) If yes, please describe the diet and reasons for following: Who purchases and prepares your food? 15. What is your current weight? What is your height? Other Please provide any other notes regarding your health goals: Thank you for filling out the Lifestyle Questionnaire. Please save a completed copy for your personal use. You can use this copy to compare your progress with a questionnaire on the final day of the program. If yes, please describe: minutes of cardiovascular activity, times per week minutes of strength or resistance training, times per week minutes of flexibility training, times per week 12. Please list your favorite physical activities: Weight History 13. What would you like to do with your weight? lose maintain gain 14. What was your lowest weight in the past five years? Your highest?

2 Gauging Your Nutrition and Activity Psychological Health Think about the past day. Have you found yourself doing any of the following? If yes, check the box and describe what happened. justification What happened? _ exaggerated thinking What happened? _ all or nothing thinking What happened? _ unhelpful rules What happened? _ When you have these types of thoughts again, what will you do to help you to stay on track with your lifestyle change?

3 Health Goals 1. What are your one-month, one-year, and five-year health, nutrition, and/or fitness goals: 2. What are the two to three biggest barriers to achieving these goals? What are the two to three greatest strengths that will help you to achieve these goals? Please check the box that best describes how ready you are to permanently commit to your lifestyle change Do not believe I need to commit Would like to commit, but don t think that I can Will commit soon Recently started to commit (past 6 months) Would like to intensify commitment Made commitment, but relapsed 5. On a scale of 1-10, how important is this change to you? 6. On a scale of 1-10, how confident are you that you will achieve this change? Health Information 7. How would you describe your health? Excellent Good Fair Poor Physical Activity 11. Are you currently physically active? 8. When was the last time you visited your physician? Nutrition History 9. Have you ever followed a modified diet to manage a health condition? If yes, please describe: 10. Do you follow a specialized diet (low carb, gluten-free, vegan, etc). If yes, please describe the diet and reasons for following: Who purchases and prepares your food? If yes, please describe: minutes of cardiovascular activity, times per week minutes of strength or resistance training, times per week minutes of flexibility training, times per week 12. Please list your favorite physical activities: Weight History 13. What would you like to do with your weight? lose maintain gain 14. What was your lowest weight in the past five years? Your highest? 15. What is your current weight? What is your height?

4 Questions Specific to this Lifestyle Change Program: 16. On a scale of 1 to 10 how useful was this program in helping you to make a lifestyle change? (1=not useful, 5=average, 10=extremely useful) 17. Would you recommend this program to a colleague? 18. What did you like best about this program? 19. How can we improve? Thank you for filling out the final Lifestyle Questionnaire. Please compare this copy to your copy from day one!

5 Setting smart Goals Long-term SMART goals are those specific, measurable, attainable, relevant, and time-bound goals that you hope to have achieved in the next 6 months to one year and beyond. These are the goals that you will make slow and steady progress towards achieving each time you achieve your short-term SMART goals. The short-term goals are measured in days, weeks, and months. EXAMPLE: I am going to eat at least seven servings per day of fruits and vegetables by the end of summer. EXAMPLE: i am going to lose 30 pounds in the next year by exercising at least 20 minutes most days of the week and only eating a dessert once per week. EXAMPLE: i am going to break the cycle of emotional eating within the next six months by eating every meal at the kitchen table without any distractions. LONG TERM GOAL Nutrition goal: #1. Physical activity goal: #1. Behavioral goal: #1. SHORT TERM Nutrition goal: #1. Physical activity goal: #1. Behavioral goal: #1.

6 Taking the Big View Barriers to and Supports for Lifestyle Change public policy community (cultural values, norms) schools (environment, ethos) Interpersonal (social network) Individual (knowledge, attitude, skills) Looking at this graphic, identify barriers and supports for your lifestyle change within each domain: Domain Barriers Supports Individual Interpersonal School Community Public Policy Now, identify what you think overall will be the 2 biggest barriers to you sustaining your lifestyle change. Describe how you might use your supports and other tools to overcome them