Today's Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
How do I picture my best health?
*
How would I like to feel and look? What activities would I like to be able to do?
What is most important as I think about the picture of my best health?
*
Where are you now? On a scale of 1 (low) to 10 (high), how would you rate this area of your life?
Why did you choose this number?
Where would you like to be?
What changes could you make to help you get there?
Where are you now? On a scale of 1 (low) to 10 (high), how would you rate this area of your life?
Why did you choose this number?
Where would you like to be?
What changes could you make to help you get there?
Where are you now? On a scale of 1 (low) to 10 (high), how would you rate this area of your life?
Why did you choose this number?
Where would you like to be?
What changes could you make to help you get there?
Where are you now? On a scale of 1 (low) to 10 (high), how would you rate this area of your life?
Why did you choose this number?
Where would you like to be?
What changes could you make to help you get there?
Where are you now? On a scale of 1 (low) to 10 (high), how would you rate this area of your life?
Why did you choose this number?
Where would you like to be?
What changes could you make to help you get there?
Where are you now? On a scale of 1 (low) to 10 (high), how would you rate this area of your life?
Why did you choose this number?
Where would you like to be?
What changes could you make to help you get there?
Where are you now? On a scale of 1 (low) to 10 (high), how would you rate this area of your life?
Why did you choose this number?
Where would you like to be?
What changes could you make to help you get there?
Where are you now? On a scale of 1 (low) to 10 (high), how would you rate this area of your life?
Why did you choose this number?
Where would you like to be?
What changes could you make to help you get there?
Where are you now? On a scale of 1 (low) to 10 (high), how would you rate this area of your life?
Why did you choose this number?
Where would you like to be?
What changes could you make to help you get there?
What stands out for you as significant about where you currently are in any given area of the Wheel of Health?
If nothing changes in your health and well-being choices, what do you think your health will be like three years or ten years from now? What would be the worst-case scenario?
If you make significant health behavior changes, what do you think your health will be like three years or ten years from now? What would be the best-case scenario?
Mindfulness Awareness
Movement, Exercise and Rest
Nutrition
Personal and Professional Development
Physical Environment
Relationships and Communication
Spirituality
Mind–Body Connection
Professional Care Prevention and Intervention
What area(s) of your health would you like to focus on now? What specific long-range outcome(s) would you like to achieve?
What 3–6 month SMART goal(s) would help you meet the outcome you desire?
For example, exercising three times a week on Monday, Wednesday and Friday after work for an hour each time, eating a 1,500-calorie well-balanced diet daily, etc.
Your SMART goal should be:
Specific: Your goals should be clear and concise. If your goal is not specific, it is difficult to know when your action begins and when it is complete.
Measurable: A goal should be measurable so you can track your progress. You need to have clear criteria for progress and completion when taking action on a goal. Keeping track of your progress can be inspiring.
Action-Oriented: A goal should include action, and that action should be in your direct control.
Realistic: A goal should be realistic. It is best to work on small lifestyle changes that are easy to complete. Focus on the small steps instead of feeling overwhelmed by the big picture.
Timed: A goal should be tied to a timetable for completing specific, measurable and realistic action.
Is there more than one option for meeting your SMART goal? If so, what are these options? Which one(s) appeal to you now to get you started?
For example, if your goal is to begin exercising three times a week after work on Monday, Wednesday and Friday for an hour each session, what kinds of exercise appeal to you? Would you like to exercise alone or with others? What options would you like to consider?
What are the SMART steps you want to start in Week One to begin working on your 3–6 month goal(s)?
For example, do you need to purchase any equipment such as a bike or bike helmet, running shoes or gym membership? Do you want to start exercising this week for 20 minutes at a time to work up to your goal of one hour each time? Do you need to speak with a medical provider for clearance for a new exercise program? Do you need to meet with a nutritionist to plan a well-balanced diet? Make sure the SMART steps meet the same criteria as the SMART goals.
SMART Step 1
SMART Step 2
SMART Step 3
SMART Step 4
SMART Step 1
SMART Step 2
SMART Step 3
SMART Step 4
What have you learned about yourself from other times you have made changes to your health and lifestyle? What strengths do you bring to your health goals?
Are you skillful at planning new initiatives? Can you bring your organizational, planning and tracking skills to this new behavior change? How will you do that?
Do you have more energy and time in the mornings or evenings?
Do you have more success when you plan goals that include connection with other people, or do you prefer to work alone?
Barrier 1
Strategy
Barrier 2
Strategy
Barrier 3
Strategy
Barrier 4
Strategy
How will you hold yourself accountable and to whom?
