Behavior Change Activity

The following is a worksheet that need to be completed I attached the following paper that has all the instructions on how to do it step by step with the questions also.

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Behavior Change Activity
1. Write two general behaviors you wish to change (i.e. your overall goal).
Example: I want to floss my teeth more often.
Behavior 1:
Behavior 2:
2. Assess your stage of change for each behavior. (See Stages of Change.)
Example: I am in the preparation stage.
Behavior 1:
Behavior 2:
3. Explain why you think you are in this stage. If you are not ready to change (in pre-contemplation
or contemplation stage, select another behavior.)
I intend to begin within the next 30 days.
I realize that the benefits of flossing my teeth (fresh breath, clean teeth, preventing future problems
with teeth) outweigh the barriers.
I am beginning to think about the details of change.
Behavior 1:
Behavior 2:
4. Explain why you want to change this behavior (think: What is your why?)
Behavior 1:
Behavior 2:
5. Now create 2 to 3 specific objectives (the “specifics” – include who, what, how much, by when).
These should support your overall goal.
? I will buy one package of floss by February 1st.
? I will ask my dentist how to best floss my teeth at my next cleaning on March 12.
? I will floss my teeth when I get up in the morning at least 5 times/week (Su-Th) beginning on Nov. 23.
Behavior 1 Objectives:
Behavior 2 Objectives:
6. Double check each objective fits the SMART criteria.
? Is it Specific? Yes, includes who, what, how much, when.
? *Is it Measurable? Yes, measured by whether I…(ex: BMI, body fat, journal, expenses, etc.)
? Is it Achievable? Yes, I am capable of doing this.
? Is it Realistic? Yes, I am likely to succeed.
? Is it Time-oriented? Yes, I have dates for each task, and I have a date when I will begin.
? Does it answer who, what, how, much, and by when?
7. Next, write down what barriers might you encounter when changing each behavior. How will you
overcome these barriers? Who or what can be used to positively reinforce your new behavior?
How so?
Plan to Overcome
+ Reinforcers/Enablers;
How so

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