Contract

Health Improvement Project Contract

Name:                                                                                                 Date:                       

Health habit or behavior I intent to change:

Goal to be reached (in specific terms):

Current self-assessed status (refer to self-assessment scale from Martin’s Index of Health Behavior on page 7):

Benefits I anticipate as a result of the change:

Any benefits of not changing?:

What will happen if I don’t change?:

Specific activities, behaviors, attitudes, or thoughts I will monitor and chart during the 9-week period:

Target date to reach goal:                                     

Indicators of successful achievement of my health behavior change will be:

How I will reward myself (daily, weekly, overall) for this change:

Names and phone numbers of HIP partners and times to meet to discuss progress:

Signature:                                                                                

Instructor’s Signature: