Self -Assessment Assignment

Fall 2010

1. Complete the Self Assessment in your booklet, pages 1-9. You do need to turn them in
to me along with answers to the questions to the following questions. Examine your results.
Answer the following questions regarding your self- assessment results:
a. If your health behaviors remain unchanged over the next 20 years, what would
you expect your health to be like at that time? Note: Be specific. For what
chronic conditions are you putting yourself at risk? Are your health behaviors
leading you toward a healthy life?
b. What changes in your health behaviors would reduce your risk the most? Can be
more than one.
c. What health behaviors are you willing to change at this time?

2. Choose a health behavior you wish to change over the course of the semester. Create a
plan for making the change and a realistic goal to achieve by the end of the semester.
Select an approach to changing behavior which will most likely help you succeed.
Complete the contract that is attached to this assignment.

3. Submit the answers to #1 and your contract by August 31st. I will return the
contracts on September 7th.

4. Carry out your planned approach to change over the course of the semester. At midterm,
we may review your progress.

5. At the end of the semester, resubmit your contract and a written report of your progress
including the following:
a. Why is this behavior change important to you?
b. Were you successful at reaching your goal and following your plan?
c. Why were you (or were you not) successful in accomplishing your goal?
d. What insights have you gained about changing health behavior?
e. What are your plans for continuing your new health behavior (if you were
successful) or for accomplishing your original goal (if you were not successful).

Note: You must turn in the contract and answers to the five questions listed in #5 above to
receive full credit.

Final Report Due: November 30th

 My Contract for Change

Date: August 25, 2010

Personal Goal: My goal for this semester is to fix my personal eating habits and to incorporate more
food groups into my daily meals.

Motivating Factors: One of my motivating factors is my boyfriend because he loves to cook but always
has to make my food “special” because I am such a picky eater.

Change(s) I Plan to Make to Reach This Goal: Some of the changes I plan to make are incorporating
more of the food groups into my daily eating habits. I also plan to try to challenge myself in trying new
foods that I have been afraid to try in the past.

Plan for Making This Change: I plan to watch what I eat for two weeks and when I eat it and try to go by
that into what I need more of in my diet and what I need less of in my diet. The biggest one would
probably be junk food so I plan to help slowly cut that out of my diet as well. With being an athlete I
watch what I eat but not necessarily eat the right things.

Plan to Track Progress: I plan to track my progress through a journal and a chart that tells when I eat and
what I eat at that time.

If I Need Help: I plan to ask for help and have people persuade me to try new things

Target Date for Achieving Goal: My birthday at the end of the semester December 3

Reward for Achieving Goal: Eating new and healthier foods

Penalty for Failing to Achieve Goal: I will work harder in my workouts with aerobic and anaerobic
programs to make up for all the bad foods that I eat.

_______________________________________________________________________

Signed: ________________________________________________________________

Witnessed By: __________________________________________________________