write about your experience for others and to apply the stages of change 
theory (transtheoretical model) and concepts related to motivational interviewing, OARS and microskills as 
applicable. 
Your reading audience for the paper is individuals who do not know anything about the health behavior concepts 
discussed in class (Stages of Change Theory, Motivational Interviewing, OARS, Microskills) – think family or friends 
that are not in pharmacy school.
Pre assessment
Prior to this course, I have participated in a similar health behavior change assignment in
another class/course.
Yes
No
HEALTH BEHAVIOR CHANGE
What is my target health behavior? (Explain, be as specific as possible.)
My target health behavior is eating healthy food.
What are specific daily or weekly goals for my target behavior? List a 2 – 3 goals and
indicate if daily or weekly goal. If only have two goals, please place N/A for Goal 3.
Daily or Weekly Goal
Daily
Goal 1
Eat more vegetable and fruit
Goal 2
Cook food
Goal 3
Go to the market and buy groceries
What is my current Stage of Readiness to Change for my target behavior?
Precontemplation (not at all ready; not really thinking about it, it’s not that important)
Contemplation (have been thinking about it; I know I need to; I’ll get to it eventually)
Preparation (I’m ready; I’m making a plan; it’s important to me to start soon)
Weekly
Action (I have been regularly engaging in this behavior for less than 6 months)
Maintenance (I have been regularly engaging in this behavior for more than 6 months)
My level of intention to carry out these goals is:
Not at all intending
1
2
Level of Intention
Very much intending
3
4
5
6
7
8
9
10
What are the top 2- 3 reasons why I believe I should be engaging in this behavior? If you
only have 2 reasons, please place N/A for Reason 3.
Reason 1
lose weight
Reason 2
Lower risk of disease
Reason 3
Better mood
What are the top 2 -3 barriers I will encounter for engaging in this behavior or reasons for
not engaging in this behavior? If you only have 2 barriers/reasons, please place N/A for
Reason 3.
Barrier 1
Changing habits
Barrier 2
Lack of time to cook
Barrier 3
N/A
How important is this change to me right now?
Not Important
1
2
3
4
Somewhat
5
6
7
8
Very Important
9
10
Importance
How confident am I in being able to make my targeted health behavior change?
Not at all Confident
1
2
Somewhat
3
4
5
Very Confident
6
7
8
9
10
Confidence
My top 2 – 3 reasons that I am confident in engaging in my targeted health behavior change
are: (If you only have 2 reasons, please place N/A for Reason 3.)
Reason 1
I am following up with a nutritionist
Reason 2
I read a lot about it
Reason 3
N/A
My top 2 – 3 reasons that I AM NOT confident in engaging in my targeted health behavior
change are: (If you only have 2 reasons, please place N/A for Reason 3.)
Reason 1
I tried to eat healthy before but I failed
Reason 2
It is hard on me to stay away from snacks
Reason 3
N/A
How ready am I to change the target behavior identified?
Not at all ready
1
2
Readiness
Somewhat
3
4
5
Very
ready
6
7
8
In the past, my primary coping style for changing this behavior has been more:
Approach
Avoidance
What is my current feeling toward behavior change?
Positive
9
10
Ambivalent (don’t really care one way or the other)
Resistant (just haven’t wanted to deal with it).
This assignment prompted my health behavior change.
Yes
No
If I don’t engage in this behavior change, my understanding of my health consequences are:
Short-term health consequences (provide 2 – 3 consequences). (If you only have 2 reasons,
please place N/A for Reason 3.)
Consequence 1
Lack of energy Consequence 2
Consequence 3
Gaining weight
Stress
Long-term health consequences: (provide 2 – 3 consequences) (If you only have 2 reasons,
please place N/A for Reason 3.)
Consequence 1
Obesity
Consequence 2
Develop a health problem
Consequence 3
N/A
How susceptible am I to the health consequences I identified?
Not at all susceptible
Very susceptible
1
2
3
4
Susceptible to health consequences
5
6
7
8
9
10
Who do I know who has had negative outcomes from not managing my target behavior
change?
How severe will the these potential consequences be if they do happen to me?
Not at all severe
1
2
3
4
5
6
7
8
Very severe
9
10
N/A
Severity of consequences
What is the likelihood that I can prevent these potential consequences if I engage in my
target behavior?
Not at all likely
Very likely
1
2
3
4
Likelihood can prevent consequences
5
6
7
8
9
10
Whose approval will I gain if I engage in the target behavior?
Parents
How important is the approval of this person/these persons to me?
Not at all important
1
2
Approval of others
Very important
3
4
5
6
7
8
9
10
My sense of control related to engaging in this health behavior is based on something
internal to me or outside of my control.
Internal to me
1
2
Sense of Control
Outside of my control
3
4
5
6
7
8
9
10

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