"Health Behavior Contract Template"

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Health Behavior Contract Example
th
6
Grade Health
Name _______________________________________________
1. What is your goal? (Needs to be specific)
a. Example – I will eat at least 5 fruits and veggies each day
b. Your Goal –
2. How will this goal help your health?
a. Example – I will get a lot of the vitamins and minerals I need each day as
well as increasing the amount of fiber I get.
b. Your Response –
3. Plan
a. Example
i. Have a piece of fruit, a veggie or a salad with each meal.
ii. Eat fruit or veggie for snack after school
iii. Eat fruit or veggie as night time snack or between breakfast and
lunch
b. Your Plan (must have at least 3 things you will do to reach your goal)
4. Progress
a. Example – I will put a smile face the calendar each day I reach my goal.
b. How you are going to chart your progress –
5. Did your plan work? (Needs to be written the last day of your plan)
a. Example – Yes. I ate at least 5 fruits and veggies 6 of the 7 days this
week. I am going to keep up with my plan for 3 more weeks and then it
should become a healthy habit.
b. Your response -
Health Behavior Contract Example
th
6
Grade Health
Name _______________________________________________
1. What is your goal? (Needs to be specific)
a. Example – I will eat at least 5 fruits and veggies each day
b. Your Goal –
2. How will this goal help your health?
a. Example – I will get a lot of the vitamins and minerals I need each day as
well as increasing the amount of fiber I get.
b. Your Response –
3. Plan
a. Example
i. Have a piece of fruit, a veggie or a salad with each meal.
ii. Eat fruit or veggie for snack after school
iii. Eat fruit or veggie as night time snack or between breakfast and
lunch
b. Your Plan (must have at least 3 things you will do to reach your goal)
4. Progress
a. Example – I will put a smile face the calendar each day I reach my goal.
b. How you are going to chart your progress –
5. Did your plan work? (Needs to be written the last day of your plan)
a. Example – Yes. I ate at least 5 fruits and veggies 6 of the 7 days this
week. I am going to keep up with my plan for 3 more weeks and then it
should become a healthy habit.
b. Your response -