Personal Goal Worksheet

Name __________________________________

Month __________________________________

Quit date _______________________________

Smoke free days this month ________________

Weight at beginning of month _______________

Weight at end of month ____________________

Strongest cravings, time and place:

______________________________________

______________________________________

______________________________________

Exercise goal for month:

Minutes _____________ Times a week____________

Number of cigarettes today _________________

Smoke free day

____ Ate breakfast

____ Avoided junk food snacks

____ Caffeine-free coffee/cola

____ Exercised 20 minutes or more

____ Slept 7-8 hours

____ Avoided alcohol

____ Ate low-fat foods

____ Ate vegetables 1 serving

____ Ate vegetables 2 servings

____ Ate vegetables 3+ servings

____ Ate fruits 1 serving

____ Ate fruits 2 servings

____ Ate fruits 3+ servings

____ Ate whole grains 1-2 servings

____ Ate whole grains 3-4 servings

____ Ate whole grains 5+ servings

____ Took time to relax/meditate

____ Brushed and flossed

Personal benefit log

Write down the benefits you experience from being smoke-free (for example, I can smell flowers again!) Write the specific occurrence, the date it first happened, and your reaction.

Event or experience:

__________________________________________________

__________________________________________________

__________________________________________________

Date if first happened:

__________________________________________________

__________________________________________________

__________________________________________________

My reaction:

__________________________________________________

__________________________________________________

__________________________________________________