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?_______________________________________

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How can I overcome these barriers (above) in order to reach my goal? __________________________ ______

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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? ____________________________________________

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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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