Name
Section/Time of Class
Pre-Wellness Assessment and Behavior Change Plan
Instructions
GHTH 100: Personal Wellness
This assignment is due September 15
Locate and complete the Interactive Assess Yourself inventory, which can be found online in the following
manner:



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Locate the site at www.pearsoncustom.com/va/jmu_ghth100
Two texts will appear on the screen. Click on the text to the left.
At the top of the screen, select ‘Chapter 1’.
To the left, click ‘Self-Assessments’.
Click ‘Interactive Assess Yourself.’
Complete the inventory online, and print out a copy of your results upon completion. Keep a copy of your PreAssessment results for comparison with the Post-Assessment. Use the results from your Pre-Assessment to
answer the following questions. On the due date, submit your responses to the questions below, as well as the
Behavior Change Contract which is attached. The assignment will not be accepted early.
1. Type your Pre-Wellness Assessment scores in the chart.
Category
Physical Fitness
Social Health
Emotional Health
Environmental Health
Spiritual Health
Intellectual Health
Personal Health Promotion and Disease
Prevention
Pre-Wellness Assessment Total Score
Ideal Score
40
40
40
40
40
40
40
Your Score
280
Answer questions 2-7 based on the Pre-Wellness Assessment results. Highlight your responses on this page.
2. The category for my Pre-Assessment overall score is:
a.
b.
c.
d.
245-280 points – Excellent or High Level Wellness
210-244 points – Good or Many Positives/Need Some Improvement
140-209 points – Your Health Risks are Beginning to Show
Less than 140 points – Needs Improvement or Choices Adverse to Health
3. My Pre-Asessment overall score is:
a. A complete surprise to me
b. Somewhat expected
c. Exactly what I expect
4. Which of the following responses best reflects your feelings/thoughts about your score:
a.
I am aware of areas I do well and areas I need to change and the score accurately reflects my health
behaviors.
b. I am aware of areas I do well and areas I need to change, however the score does not accurately
reflect my health behaviors.
c. There is more to health than I realized and the score accurately reflects my health behaviors.
d. There is more to health than I realized and the score still seems off in relation to how I feel about my
health.
5. List 5 positive health behaviors or practices that you currently engage in and plan to
maintain.
6. List 5 negative health behaviors or practices that you currently engage in.
7. List 3 health behaviors that you will make attempts to engage in this semester. You may add positive behaviors that
you are not practicing and/or stop negative behaviors that you are practicing.
Complete the Assess Yourself questionnaire and read the Skills for Behavior Change box describing the stages of
change. After reviewing your results and considering the various factors that influence your decisions, choose a
health behavior that you would like to change, starting this semester. Sign the contract at the bottom to affirm
your commitment to making a healthy change and ask a friend to witness it.
My behavior change will be: _____________________________________________________________________________
My long-term goal for this behavior change is: _______________________________________________________________
These are three obstacles to change (things that I am currently doing or situations that contribute to this behavior or make it harder to
change):
1.
2.
3.
___________________________________________________________
___________________________________________________________
___________________________________________________________
The strategies I will use to overcome these obstacles are:
1.
2.
3.
___________________________________________________________
___________________________________________________________
___________________________________________________________
Resources I will use to help me change this behavior include:
A friend/partner/relative:
A school-based resource:
A community-based resource:
A book or reputable website:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
In order to make my goal more attainable, I have devised these short-term goals
__________________________________
Short-term goal
____________
Target date
_________________
Reward
__________________________________
Short-term goal
____________
Target date
_________________
Reward
__________________________________
Short-term goal
____________
Target date
_________________
Reward
When I make the long-term behavior change described above, my reward will be:
_______________________________________________
Target date: _________
I intend to make the behavior change described above. I will use the strategies and rewards to achieve the goals that will contribute to a
healthy behavior change.
__________________________________
Signature
_________________________________________
Witness