Healthy Changes: Setting Goals & Making Plans
Is there one thing that you would like to change
that would help you be healthier? This
worksheet can help you decide how to start.
Some ideas are listed below, but feel free to
choose other topics.
Change can be hard. You may have one
goal or a number of goals to reach. Don’t try
to reach all of your goals at once. Make a
plan to help you take things step by step.
Small successes will give you confidence
and lead to more success!
Activity Emotional Health
Monitoring Nutrition Pain
The change I want to make is: __________________________________________________
Please circle the number below that shows how important it is to you to make this change:
Not important Very important
1 2 3 4 5 6 7 8 9 10
My Goal and Plan for a Healthy Change
It is easier to make a change when you set a goal and make a plan to reach it. Please fill in the blanks
below and share your answers with your health care team who can support you.
My goal for next week or month (circle one) is:
I will ___________________________________________________________________
This is my plan to reach my goal:
How much: __________________________________________________________________
How often: ___________________________________________________________________
Resources and support I will need to reach my goal: ________________________________________
Things that could make it hard to reach my goal: ___________________________________________
This is how I will deal with these things: _________________________________________________
Please circle the number below that shows how sure you are (confident) that you can reach your goal:
Not sure Very sure
1 2 3 4 5 6 7 8 9 10
You are more likely to reach your goal when your confidence level is a 7 or more.
If you chose a number below 7, think about ways to change your goal or plan so you feel more sure that
your plan will work and you will reach your goal.
I will follow-up with ________________________ by ______________________ on _____________.
Who How - phone, e-mail, in-person, other Date & Time
Your health care team may have given you this information as part of your care. If so, please use it and call if you have any
questions. If this information was not given to you as part of your care, please check with your doctor. This is not medical
advice. This is not to be used for diagnosis or treatment of any medical condition. Because each person’s health needs are
different, you should talk with your doctor or others on your health care team when using this information. If you have an
emergency, please call 911. Copyright © 2/2016 University of Wisconsin Hospitals and Clinics Authority. All rights reserved.
Produced by the Department of Nursing. HF#7523.