ASSIGNMENT 1a.

Behavior Modification: Stages of Change

Instructions:

Indicate which response most accurately describes your stage of change for two different
behaviors (in the blank space identify the behavior: physical activity, weight control, nutrition,
stress, smoking).

Next, select the statement (select only one) that best represents your current behavior pattern.

To select the most appropriate statement, fill in the blank for one of the statements if your current
behavior is a problem behavior. (For example, you might say, “I currently smoke and I do not
intend to change in the foreseeable future.” or “I currently do not exercise but I am contemplating
changing in the next 6 months.”

If you have already started to make changes, fill in the blank in one of the last two statements.

(In this case, you might say: “I currently eat a low-fat diet but I have done so only within the last 6
months,” or “I currently practice adequate stress management techniques and I have done so for
more than 6 months.”) You may use this technique to identify your stage of change for any type of
health-related behavior.

Example:

Behavior 1: Physical activity__

1. I currently _____________________, and I do not intend to change in the foreseeable future.

2. I currently _____________________, but I am contemplating changing in the next 6 months.
3. I currently _____________________, regularly but intend to change in the next month.
4. I currently _____________________, but I have done so only within the last 6 months.
5. I currently _____________________, and I have done so for more than 6 months.

Answer:

Selected statement: Number 5 with the following complete statement:

5. I currently take a walk from my house going to Brgy. road way to ride a jeepney transportation
with route going to school campus and from outside the campus at where I intend the jeepney to
stop & drop by, I take a walk again going inside to the school campus and department office for
duty, and I have done so for more than 6 months.

Stage of change: _Maintenance__

Specific goal and date to be accomplished: _Daily routine for cardiorespiratory endurance exercise
Example:

Behavior 2: _Nutrition__

1. I currently _____________________, and I do not intend to change in the foreseeable future.

2. I currently _____________________, but I am contemplating changing in the next 6 months.

3. I currently _____________________, regularly but intend to change in the next month.

4. I currently _____________________, but I have done so only within the last 6 months.

5. I currently _____________________, and I have done so for more than 6 months.

Answer:

Selected statement: Number 3. with the following complete statement:

3. I currently seldom eat preferred cook meal at home, I opted to visit fast food chain for a meal,
regularly but intend to change in the next month.

Stage of change: __Preparation__

Specific goal and date to be accomplished: To rely on a meal not always on the fast-food chain but
to consider food preparation specially fruits & vegetable included for meal at home.

Stages of Change

1 = Precontemplation 4 = Action

2 = Contemplation 5 = Maintenance

3 = Preparation 6 = Termination/Adoption
Now, it’s your turn!

Behavior 1: _________________

1. I currently _____________________, and I do not intend to change in the foreseeable future.

2. I currently _____________________, but I am contemplating changing in the next 6 months.
3. I currently _____________________, regularly but intend to change in the next month.
4. I currently _____________________, but I have done so only within the last 6 months.
5. I currently _____________________, and I have done so for more than 6 months.

Selected statement: Number ___ with the following complete statement:

______________________________________________________________________________
______________________________________________________________________________
___________________________________________

Stage of change: ______________

Specific goal and date to be accomplished:

______________________________________________________________________________________
____________________________________________

Behavior 2: _________________

1. I currently _____________________, and I do not intend to change in the foreseeable future.

2. I currently _____________________, but I am contemplating changing in the next 6 months.

3. I currently _____________________, regularly but intend to change in the next month.

4. I currently _____________________, but I have done so only within the last 6 months.

5. I currently _____________________, and I have done so for more than 6 months.

Selected statement: Number ___ with the following complete statement:

______________________________________________________________________________
______________________________________________________________________________
___________________________________________

Stage of change: ____________________

Specific goal and date to be accomplished:

______________________________________________________________________________________

_________________________________________________________
 ASSIGNMENT 1b.

SMART Goal Sheet for Physical Activity

Specific: What are you going to do?

Measurable: How much or how long? How often? How will I know if I have achieved it?
Attainable: What are you going to do to reach your goal?
Realistic: Why is this important to you? Do you believe you can achieve this?
Time-specific: When will you start? How will you monitor your progress towards your goal?

Sample SMART goal: By the end of the month, I will be walking 20 minutes per day, three times a
week.
Action Steps Anticipated Barriers Contingencies
Identify the walking route. Rain Walk indoors (e.g. treadmill);
Follow a group exercise video

Walk with mp3 player during

Find a walking partner. Friend is busy
solo walks

Start studying for an exam days

Schedule this after my class Study for an exam
before the date

Now, it’s your turn!

Write your SMART goals that will aid with the process of change for physical activity.

SMART Goal Sheet for Physical Activity

Specific: ___________________________________________
Measurable: ____________________________________________
Attainable: ____________________________________________
Realistic: ____________________________________________
Time-specific: ____________________________________________

Action Steps Anticipated Barriers Contingencies

Submit your assignment 1a & 1b answers by encoding it in the ‘word’ document, with your name &
PE12 section in eLearn.

Please use the following format when uploading your assignments:

Filename: Assignment1_surname (Example: Assignment1_delaCruz)

Paper: Legal, Portrait
Font: Arial, 12

Read each statement in the Health Appraisal Questionnaire, fill up & submit by clicking the URL
icon posted in eLearn to access the form.