Spring 2017 Health Behavior Diary Template http://www.bettycjung.net/Pch201grids.htm Read the Writing Assignments Handbook first! Summary of Required One Week Health Behavior Diary Assignment The health diary must be at least 6 single-spaced written pages. It can be longer, but it must not be shorter than 6 pages. The number in parentheses is an estimate of how long each section should be. Your paper should include: • Statement of Intent. Why this particular behavior(s)? (1/2 page) • Daily log of your thoughts and actions during the week, starting on midnight, Sunday and ending midnight, Saturday (2 pages) • Summarize the week by reflecting on the value of changing this particular behavior(s), and your feelings about how successful (or unsuccessful) you were, what barriers you encountered, etc. What did you learn from this experience? Was it hard? Could you make it a permanent change? If not, what would you do differently? (1 page) • Evaluate your experience, using the grid provided (1 page) • Rate your chances for success in maintaining the change. (1/2 page) Submit this grading grid with your Health Behavior Change Diary Paper One Week Health Behavior Change Diary (Sunday to Saturday Week) http://www.bettycjung.net/Pch201grids.htm Due Date: ___________________________________________ Week of: _________________________________________ Name: ______________________________________________ Health Behavior(s): _____________________________________ Date submitted: ______________________________________ CATEGORY POINTS SCORE Used Template Clarity of Thought Coherence in organization Grammar Punctuation Spelling 6 pages Handbook Compliant 2 Statement of Intent (Why this particular behavior) 2 Daily log of your thoughts and actions during the week (There should be an entry for each day) 14 Evaluate your health behavior change experience 3 What Did You Learn From This Experience? 3 Rate your future success with your behavior change 1 SUBTOTAL 25 LATE/INCOMPLETE (- 20% of total points) (-20%) Missing grading grid (-3) FINAL TOTAL POINTS 25 Here is the template to use for writing your Health Diary Paper Health Behavior Diary Selected Behavior: _______________________________ Statement of Intent Write a paragraph or two about why you decided to change this particular behavior and what you hope to achieve by the end of the week. One-week Daily Log Make sure there is an entry every day. Replace what is in red with your narrative, and put the appropriate date into the date box (you can use black ink instead of red). The boxes will expand to accommodate your entries. Day 1 Sunday Date: 00/00/0000 At the end of day write a paragraph or two about your experiences with your chosen health behavior change(s) Day 2 Monday Date: 00/00/0000 At the end of day write a paragraph or two about your experiences with your chosen health behavior change(s) Day 3 Tuesday Date: 00/00/0000 At the end of day write a paragraph or two about your experiences with your chosen health behavior change(s) Day 4 Wednesday Date: 00/00/0000 At the end of day write a paragraph or two about your experiences with your chosen health behavior change(s) Day 5 Thursday Date: 00/00/0000 At the end of day write a paragraph or two about your experiences with your chosen health behavior change(s) Day 6 Friday Date: 00/00/0000 At the end of day write a paragraph or two about your experiences with your chosen health behavior change(s) Day 7 Saturday Date: 00/00/0000 At the end of day write a paragraph or two about your experiences with your chosen health behavior change(s) Health Behavior Change Experience Evaluation Grid Evaluate the following statements as to how much you agree with them. Circle the number you feel best represents your level of agreement or disagreement with the statement (You can do this by hand). Scale (1=Disagree a lot, 5=Agree a lot) Q Statement Disagree Agree 1 Being a required assignment help making the change easier 1 2 3 4 5 2 Maintaining the change got easier as time went on 1 2 3 4 5 3 Maintaining the change got harder as time went on 1 2 3 4 5 4 I had to make changes in my life to maintain the behavior change 1 2 3 4 5 5 I wasn’t sure if I could maintain the change for a whole week 1 2 3 4 5 6 I was confident, as the week went on, that I can maintain the change 1 2 3 4 5 7 After making and maintaining the change for one week I know I can make this a permanent change 1 2 3 4 5 8 The change will be beneficial for my health in the long run 1 2 3 4 5 9 Based on my experience with this behavior change I know I can make other changes in my life to improve my health 1 2 3 4 5 What Did You Learn from This Experience? Summarize the week by reflecting on the value of changing this particular behavior or behaviors, and your feelings about how successful (or unsuccessful) you were, what barriers you encountered, what motivated you, etc. What did you learn from this experience? Was it hard? Could you make it a permanent change? If not, what would you do differently? Rate Your Future Success with Your Health Behavior Change Write in a percentage of how successful you think you will be able to maintain this change in the long term after the one-week change (e.g., 0% = unlikely, 50% = somewhat likely, 100% extremely likely). % Revised 11/23/2016