Personal Health Behavior Contract
Based on an awareness of my personal health status, I,
_________________________, have decided to set the following
health behavior improvement goal, and I will strive to achieve
this between the following dates, __________________________.
My health behavior goal is ________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
The advantages to me for achieving this goal are _____________
_______________________________________________________
_______________________________________________________
The difficulties for me in doing this are _____________________
_______________________________________________________
_______________________________________________________
The ways that I will try to accomplish this health behavior
improvement goal are ____________________________________
_______________________________________________________
_______________________________________________________
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If I have achieved this health behavior improvement goal by
________________, I will reward myself by __________________
_______________________________________________________
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If I fail to achieve this health behavior improvement goal, I will
forfeit this reward.
Signed: ________________________________________________
I, _______________________________________________, have
reviewed this contract and I agree to discuss the experience
involved in accomplishing or not accomplishing this health
behavior improvement with ______________________ on
_______________________________.
Signed (witness): ________________________________________
Phone number/email: ____________________________________