Wellness Activity & Nutrition Daily Survey © Mon Tue Wed Thu Fri Sat Sun
Name: Date:
LIFETIME PHYSICAL ACTIVITY & EXERCISE (45 points possible) Pts.
It is possible to earn 1 point for each minute of moderate to virorous intensity activity you do, 45 points is the
maximum (moderate intensity = brisk walking, stair climbing, gardening, dancing, swimming, etc.) 45
WHAT DID I DRINK? (10 points possible) Pts.
I drank a healthy amount of water 6
I limited milk and dairy consumption to 1 or 2 servings 2
I limited fruit juice consumption to only 1 glass 2
I had 1 - 2 sugar based drinks (soda, energy drinks, fruit cocktail drinks, etc.) -3
I had more than 2 sugar based drinks (soda, energy drinks, fruit cocktail drinks, etc.) -8
SUBTOTAL
WHAT DID I EAT? - HEALTHY PROTEIN (10 points possible) Pts.
If I ate protein types of foods I chose to eat fish, poultry, eggs, tofu, nuts or beans 8
I limited my consumption of red meat, cheese and other high fat dairy products 1
I avoided eating bacon, cold cuts, and other processed meats 1
I ate bacon, cold cuts, or other processed meats -3
SUBTOTAL
WHAT DID I EAT? - WHOLE GRAINS (10 points possible) Pts.
If I ate grains I ate whole grains like brown rice, quinoa, whole-wheat bread or whole-grain pasta 10
I ate refined grains such as pastries, doughnuts, white rice and white bread or pasta -3
SUBTOTAL
WHAT DID I EAT? - FRUITS AND VEGETABLES (10 points possible) Pts.
I ate fruits that were a variety of colors (1 point for every fruit up to 4 fruits) 4
A variety of vegetables were the predominant food source for me (potatoes & french fries don't count) 6
SUBTOTAL
WHAT DID I EAT? - HEALTHY OILS (5 points possible) Pts.
I used healthy oils (olive, canola, corn, etc.) for cooking, on salad, and with with other foods 5
FEELINGS & BEHAVIOR (10 points possible) Pts.
I was satisfied after eating meals & felt neither hungry nor over-full 2
I chose to eat healthy regardless of my envorinment or circumstances 2
I made a conscious effort to avoid trans-fats and excitotoxins (food additives like MSG & aspartame) 2
I felt a sense of accomplishment and satisfaction in my physical activity / exercise participation 2
I limited or avioded salty, savory, or sweet snacks including junk food and candy 2
SUBTOTAL
TOTAL POINTS POSSIBLE PER DAY = 100
TOTAL DAILY POINTS
The My Wellness Activity/Exercise Worksheet is intended to be used as a guide for promoting healthy behaviors and reducing risk for many chronic diseases. Daily physical
activity and exercise combined with a prudent healthy diet has been shown to be very effective in maintaining a healthy weight as well as lowering the risks of heart disease,
cancer, diabetes, stroke, and other diseases. This worksheet is designed to help you make changes for the better and take charge of your own daily choices, and your own good
health. Physical activity and exercise can be accumulated over the course of a day in multiple bouts (i.e., three 10-min. sessions = 30 pts.,etc.) Good Luck with your healthy
lifestyle changes, and remember, you don't have to be perfect to have success! Typically, balance, variety, and moderation results in the greatest potential for long-term change.
A key to success for many has been to average 80 points per day over the course of the week.
Copyright 2014 - Ron Hager & Barbara Lockhart
