Client's full name:

Laura Van Baalen

RESOURCES
FOR
EXERCISE
MAINTENANCE
This assessment is a set of questions
we use to best
tailer
an exercise plan
and support methods based on you as a unique
person. Please fill in the most correct response (1 to 5) based on how the corresponding item describes you. There are no
right or wrong answers. Your answers will be kept stricty confidential.
1 = Strongly Disagree
5 = Strongly Agree
1
2
3
4
5
1
Regular physical activity makes me feel better.
5
2

I've never been a person who sets clear goals.

My friends support my interests and efforts.

I believe that regular physical activity is needed for good health.

When physical activities get stressful, I stop them.

I'm good at applying myself to new tasks.

Physical exertion is rarely enjoyable for me.

My family members support my interests and efforts

3
4
5
3
4
3
5

1 = Strongly Disagree
1
2
3

5 = Strongly Agree
4
5

I can persist when a task is tiring, uncomfortable, and/or painful.

10

I am responsible for my own success.

11

I find it difficult using "self-control" to keep myself successful.

12

Regular physical activity makes me look better.

13

I don't like to over extend myself physically.

14

I don't have people around who support my interests and efforts.

15

I avoid physical activity when I can.

5
3
1
3

= Strongly Agree

Total REMS Score

32

All People will be worked with regardless of score

Score 9-39 REMS 1,2,3

Score 40-45 REMS 4,5
This client's REMS rating is:
REMS 1,2,3
Subscales:
SM
ATD
Self-Management Skills
Social Support
Ability to Tolerate Discomfort

SELF-MANAGEMENT SKILLS
Review the appropriate self management skill handout
Initial Appointment
Follow-Up 1 of 5
Follow-Up 2 of 5
Follow-Up 3 of 5
Follow-Up 4 of 5
Follow-Up 5 of 5

Goal Setting, Dissociation

Relapse Prevention Part 1
Relapse Prevention Part 2
Thought Restructuring
Exercise Triggers, Self-Reward
Review of All Self-Management Skills

3/25/2014 10 minutes spent on this

es spent on this

PERSONAL GOAL PROFILE

Client's Full Name:

REMS level:

REMS 1,2,3

REMS Subscales:

SM

The Most Important Page that everything else loads up

ATD

Initial appointment is Long Term Goals

Follow up 1 = break down to short term

Laura Van Baalen

INITIAL APPT ONLY:

FOLLOW-UP APPT 1 of 5:

We are extremely concerned with helping you attain your personal

exercise and wellness related goals and will work with you to customize
a plan to suit your specific needs. Please identify the goals that you
have concerning your new exercise program; be as specific as possible.
Typically, goals will be based upon improving:

Below are the long-term goals you have concerning your exercise program. Today, for each long-term goal,
we need to determine the following:

1) Is this still your long-term goal?

2) On a scale from 1 - 10, how far are you right now from attaining that goal?
3) What are the short-term process goals that will help you reach your long-term goal?
FOLLOW-UP APPT 2 of 5 through 5 of 5:

(a) physical and/or mental health and well being

(b) physical appearance
(c) day-to-day functioning
(d) sport performance

Below are the long-term goals you have concerning your exercise program. Today, for each long-term goal, we need to determine
the following:

However, there may be other areas of importance to you that should be

included. After you indicate your specific goals, rate how far you are
right now (1-10) from attaining that goal.

1) Is this still your long-term goal?

2) On a scale from 1 - 10, how far are you right now from attaining that goal?
3) What changes, if any, need to be made to your short-term process goals to help you reach your long-term goal?

Appointment Dates
Initial

Follow-Up 1 of 5

###

Tuesday, April 08, 2014

Tuesday, May 06, 2014

Tuesday, June 03, 2014

Tuesday, July 29, 2014

Tuesday, September 23, 2014

CA Graduation

# of weeks untitl
next session:

Follow-up appointment dates will appear in the yellow boxes once initial appointment date is entered as indicated
Follow-Up 2 of 5
Follow-Up 3 of 5
Follow-Up 4 of 5
Follow-Up 5 of 5

PLEASE REMEMBER TO DISCUSS GROUP EXERCISE OPTIONS

1st Long Term Goal

Lose 25 lbs in 6 months. Current weight 154.8
Far from Goal

Goal Attained
1

How far from Goal?

Appt #
(1-10)
Initial Appointment
1
Follow-Up 1 of 5
Follow-Up 2 of 5
Follow-Up 3 of 5
Follow-Up 4 of 5
Follow-Up 5 of 5

4 5

10

Shade square in black once today's rating is complete

Where I Am Now

Short-Term Goals Related to 1st Long Term Goal

Short-Term Goal to be Attained by Next Appt.

a.
b.
c.
2nd Long Term Goal
Increase energy levels

Next Appt. Date

Tuesday, April 08, 2014

Far from Goal

Goal Attained
1

How far from Goal?

Appt #
(1-10)
Initial Appointment
1
Follow-Up 1 of 5
Follow-Up 2 of 5
Follow-Up 3 of 5
Follow-Up 4 of 5
Follow-Up 5 of 5

4 5

10

Shade square in black once today's rating is complete

Short-Term Goals Related to 2nd Long Term Goal

Short-Term Goal to be Attained by Next Appt.

Where I Am Now
a.
b.
c.

Next Appt. Date

Tuesday, April 08, 2014

3rd Long Term Goal

Far from Goal

Goal Attained
1

How far from Goal?

Appt #
(1-10)
Initial Appointment
Follow-Up 1 of 5
Follow-Up 2 of 5
Follow-Up 3 of 5
Follow-Up 4 of 5
Follow-Up 5 of 5

4 5

10

Shade square in black once today's rating is complete

Where I Am Now
a.
b.
c.

Short-Term Goals Related to 3rd Long Term Goal

Short-Term Goal to be Attained by Next Appt.

Next Appt. Date

Tuesday, April 08, 2014

everything else loads up on

1st Long Term Goal Progress

Goal Achievement

10
9
8
7
6
5
4
3
2
1
0
Initial Appointment

Follow-Up 1 of 5

Follow-Up 2 of 5

Follow-Up 3 of 5

Follow-Up 4 of 5

Follow-Up 5 of 5

2nd Long Term Goal

Goal Achievement

10
9
8
7
6

5
4
3
2
1

0
Initial Appointment

Follow-Up 1 of 5

Follow-Up 2 of 5

Follow-Up 3 of 5

Follow-Up 4 of 5

Follow-Up 5 of 5

3rd Long Term Goal Progress

10

Goal Achievement

0
Initial Appointment

Follow-Up 1 of 5

Follow-Up 2 of 5

Follow-Up 3 of 5

Follow-Up 4 of 5

Follow-Up 5 of 5

PERSONAL FEELINGS INVENTORY

This is a survey that we will use to determine how your exercise program may be affecting your mood and energy
levels. Below are some words and phrases that describe how people feel. Please fill in one response each based on
your feelings over the past two weeks, including today. Scale is:
0 = Not at all
1 = A little
2 = Moderately
3 = Quite a bit
4 = Extremely
PFI not done on Follow-Up Appt. 1 of 5

Weary
Fatigued
Worn-out
Exhausted
Tired
Total

Initial 2 of 5 3 of 5 4 of 5 5 of 5
2
1
3
0
2
0
2
0
3
1
12
0
0
0
2

Initial 2 of 5 3 of 5 4 of 5 5 of 5
Full of Energy
1
3
Active
2
3
Enthusiastic
2
4
Alert
3
4
Lively
2
4
Total
10
0
0
0
18

Tense
Anxious
Restless
Nervous
Jittery
Total

Initial 2 of 5 3 of 5 4 of 5 5 of 5
1
1
1
0
2
2
1
0
2
0
7
0
0
0
3

Fatigue
20

15

12

10

0
1

0
2

0
3

Appointment #

0
4

Energy
20

15

10

0
1

Appointment #

Stress
20

15

10

0
1

Appointment #

Behavioral Contract for:

Laura Van Baalen

I have reviewed a number of individual and group exercise options with my Wellness Coach.
Together we have decided on, and documented, both long and short term goals that are agreeable
to me.
Starting today,
Tuesday, March 25, 2014
and continuing through the next
I will work to reach my short term, exercise and health related goals, completing
sessions per week or a total of
sessions during the next 4 Weeks

2
3

weeks,
exercise

My long and short term goals are as follows:

I have a long-term goal to:
Lose Weight - 25 lbs- Goal Weight of 130lbs by September 25
The following short-term goals will help me succeed at my long term goal:
a) Lose 2lbs by April 8, 2014
b)
c)
I have a long-term goal to:
Increase Energy Levels
The following short-term goals will help me succeed at my long term goal:
a) Try cycling class, yoga
b)
c)
I have a long-term goal to:
The following short-term goals will help me succeed at my long term goal:
a)
b)
c)
I agree to maintain this exercise plan until my next scheduled appointment, on
where we will make revisions as needed. I also agree to diligently log all exercise-related activity
using the method designated by my Wellness Coach.
(Participants Signature)
As your Wellness Coach, I agree to support your exercise-related needs, goals and progress through the
use of meetings, messaging, and feedback.
(Wellness Coachs Signature)

Behavioral Contract for:

I have reviewed a number of individual and group exercise options with my Wellness Coach.
Together we have decided on, and documented, both long and short term goals that are agreeable
to me.
Starting today,
Tuesday, May 06, 2014
and continuing through the next
I will work to reach my short term, exercise and health related goals, completing
sessions per week or a total of
12 sessions during the next
4
weeks.

4
3

weeks,
exercise

My long and short term goals are as follows:

I have a long-term goal to:
The following short-term goals will help me succeed at my long term goal:
a) 5lbs lost by May 6. (148lbs)
b)
c)
I have a long-term goal to:
The following short-term goals will help me succeed at my long term goal:
a) Try cycling class, yoga
b)
c)
I have a long-term goal to:
The following short-term goals will help me succeed at my long term goal:
a)
b)
c)
I agree to maintain this exercise plan until my next scheduled appointment, on
where we will make revisions as needed. I also agree to diligently log all exercise-related activity
using the method designated by my Wellness Coach.
(Participants Signature)
As your Wellness Coach, I agree to support your exercise-related needs, goals and progress through the
use of meetings, messaging, and feedback.
(Wellness Coachs Signature)

Behavioral Contract for:

Laura Van Baalen

I have reviewed a number of individual and group exercise options with my Wellness Coach.
Together we have decided on, and documented, both long and short term goals that are
agreeable to me.
Starting today,
Tuesday, May 6, 2014
and continuing through the next
I will work to reach my short term, exercise and health related goals, completing
sessions per week or a total of
12 sessions during the next
4
weeks.

4
3

weeks,
exercise

My long and short term goals are as follows:

I have a long-term goal to:
Lose 25 lbs in 6 months. Current weight 154.8
The following short-term goals will help me succeed at my long term goal:
a) Lose 4lbs (1 to 2 lbs a week) 148lbs goal
b)
c)
I have a long-term goal to:
Increase energy levels
The following short-term goals will help me succeed at my long term goal:
a) Keep going to Zumba
b)
c)
I have a long-term goal to:
The following short-term goals will help me succeed at my long term goal:
a)
b)
c)
I agree to maintain this exercise plan until my next scheduled appointment, on
Tuesday, June 3, 2014
where we will make revisions as needed. I also agree to diligently log all exercise-related activity
using the method designated by my Wellness Coach.
(Participants Signature)
As your Wellness Coach, I agree to support your exercise-related needs, goals and progress through the
use of meetings, messaging, and feedback.
(Wellness Coachs Signature)

Behavioral Contract for:

Laura Van Baalen

I have reviewed a number of individual and group exercise options with my Wellness Coach.
Together we have decided on, and documented, both long and short term goals that are
agreeable to me.
Starting today,
Tuesday, July 29, 2014
and continuing through the next
I will work to reach my short term, exercise and health related goals, completing
sessions per week or a total of
0
sessions during the next
8
weeks.

weeks,
exercise

My long and short term goals are as follows:

I have a long-term goal to:
Lose 25 lbs in 6 months. Current weight 154.8
The following short-term goals will help me succeed at my long term goal:
a)
b)
c)
I have a long-term goal to:
Increase energy levels
The following short-term goals will help me succeed at my long term goal:
a)
b)
c)
I have a long-term goal to:
The following short-term goals will help me succeed at my long term goal:
a)
b)
c)
I agree to maintain this exercise plan until my next scheduled appointment, on
Tuesday, May 06, 2014
where we will make revisions as needed. I also agree to diligently log all exercise-related activity
using the method designated by my Wellness Coach.
(Participants Signature)
As your Wellness Coach, I agree to support your exercise-related needs, goals and progress through the
use of meetings, messaging, and feedback.
(Wellness Coachs Signature)