SELF-MANANGEMENT GOAL WORKSHEET
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Swope Health Services
SELF-MANAGEMENT GOAL WORKSHEET
What barriers or blocks may keep me from reaching my goal?_______________________________________
_________________________________________________________________________________
How can I overcome these barriers (above) in order to reach my goal? __________________________ ______
_________________________________________________________________________________
How might a friend, family or healthcare team member help me meet my goal?___________________________
__________________________________________________________________________
Follow-up Visit
Date _________ Goal met? ____yes ____no
On a scale from 1 to 10, how do I feel about meeting/attempting the goal?
(10 = the best) Circle one: 1 2 3 4 5 6 7 8 9 10
If any, what one thing kept me from meeting my goal? ____________________________________________
_________________________________________________________________________________
What did I learn from working on this goal? ___________________________________________________
What’s my next step? __________________________________________________________________ Form# 01019BI Color:White File Loc: Diabetes Tab Rev. 04/06
SELF-MANAGEMENT GOAL WORKSHEET
|List which habits you want to change, stop or start |
|On a scale from 1 to 10 (1 = easy; 10 = really hard) Rate how hard will it be to change or start this habit? |
| |8 (pretty hard) |
|Example: Stop drinking regular soda pop | |
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|Choose one of these habits you are ready to change NOW and complete the other side of this form! (Hint: choose a habit that’s less than ‘5’ on your |
|scale!) |
Form# 01019CEI Color:White File Loc: Diabetes Tab Rev. 04/06
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How to set a goal:
1. Keep it simple, only one change per goal! 2. Don’t make the goal too hard. It’s OK to take small steps
3. Decide how often and when you are going to do the action. 4. Set start and end dates
Example Goal: I will walk for 30 minutes, 3 days a week for two weeks starting today.
At the end of your goal, Celebrate your success! Tell somebody!
Give yourself a pat on the back! Then set other goal date. Soon it will be a habit!
My goal is: ____________________________________________________________________
_____________________________________________________________________________
On a scale from 1 to 10, how hard do you think it will be to reach this goal? (1 = the easiest; 10 = the hardest) Circle one: 1 2 3 4 5 6 7 8 9 10
If you circled 8 or above your goal is too hard! Make your goal a little easier; then ask yourself how hard the new goal will be! The easier you think your goal is, the better chance of meeting your goal.
Date____________________ Signature_____________________________________________
Habits like
frying foods, drinks lots of soda/juice, not eating fruits and veggie, not exercising
Goals like
losing weight, getting your blood sugar, cholesterol, or blood pressure down!
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