Nutrition411 - Home Icon

oncology-centerrenal-centertoddler-kid-centerwound-resource-centerdiabetes-centernew-center

conagra
Elecare-May
Glucerna
Alliance
ensure
pediasure
California-Walnuts
Abott-Malnutrition

Change Motivation Worksheet

||

Change Motivation Worksheet

What are your long-term goal(s)?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

If you have listed more than one goal, please pick the one that you would most like to tackle first.
_____________________________________________________________________________
_____________________________________________________________________________

List the three things in your life that are most important to you.
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________

How would making this change improve your ability to nurture these three things?
1. ____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. ____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. ____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Take a few moments to picture the “new you.” How will this person differ from the person that
you are today?
Physically:______________________________________________________________________
_____________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________ Mentally:_______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
Emotionally: ___________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Take either yesterday or today as an example. How would your day have gone differently if you
would have already made the change that you are currently contemplating?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

What are you most afraid of as you embark on this new journey?

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

What could you do to prevent these fears from becoming a reality?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____

List three to five specific and measurable short-term goals that will help you to achieve your
 long-term goal. Include the date by which you would like to achieve each goal (ie, exercising for
30 minutes/day or cutting out bedtime snacks). 
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Which of these changes do you think you will find the easiest to achieve, and which will rank as
the hardest?

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

List one to three other difficult things that you have achieved in your lifetime. Did you learn any
lessons during these times that you could apply to your current challenge?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

List five ways that you could keep yourself motivated on especially hard days.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

How will you reward yourself when you reach your short-term goals? What about when you have
 achieved your long-term goal(s)?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Do you talk to yourself like a friend would? If not, write below what sort of cruel things you say
to yourself.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Now, turn every one of those statements around. What would you say if someone said those
same comments to you about someone you care about?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Would any material things make this time easier for you? Examples might include new exercise
clothes or a vegetable steamer. 
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Who will you call for support when you are having a tough time sticking to your plan?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

 

Review Date 3/09
G-0978

 

G_0978_Change_Motivation_Worksheet.doc

Viewed (10119) times.