First Name: Last Name: Weight:

Did You Eat Healthy? ( 1= Bad - 5 = Great! ) 1 2 3 4 5
Did You Exercise? ( 1= Bad - 5 = Great! ) 1 2 3 4 5

Date: Week 01 02 03 04 05 Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2006 2007 2008

Comments: (Comments are not required)

Definitions:

Healthy Eating:
Healthy eating includes an overall eating plan that features lower-fat, lower-sugar, lower-calorie foods the majority of the time. Rate yourself from 1 to 5. e.g. 1 - Oh well, I'll do better next week, 5 - I ate all the right foods and followed my Doctors recommended calorie intake each day.

Exercise:
1: No formal exercise for the week
2: Two or less 1 hour sessions
3: Three 1 hours sessions
4: Four 1 hour sessions
5: Five or more 1 hour sessions