DATE:______________ WEIGHT:__________ BONUS:_____ SCORE:______ Goal: 50 Points
SELF-IMPROVEMENT(5)
MEDITATION_______ HOBBY______MUSIC______READING_______HELPING______________
Any New Growth in Moderation_____________________________________________________
FOOD PLAN: (G:23) ___LOWFAT ___NO SUGAR ___NO WHITE FLOUR ___OTHER
BEHAVIOR CONTROL: Hunger _ _ _ _ Table _ _ _ _ _ Eating Slowly _ _ _ _ Stop When Not Hungry _ _ _ _
FOOD CONTROL: Water _ _ _ _ _ _ Sugar _ _ _ _ White Flour_ _ _ _ Salt _ _ _ _ Fat _ _ _ _
Milk(2)___ Meat(6)______ Vegetable(B)____ Bread(4)_____ Fat(5)_____ Fruit(3)___ Caffeine___
6 small Meals _________________ Reward for 350 Points___________________________________
NOTES: _______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PHYSICAL EXERCISE: (G:10) See Instructions about Points for Time Spent
Stretch Exercises__________ 1 Minute Exercise __________ Other Exercise ____________
Piano____________________ Dancing___________________ Singing __________________
Walk ____________________ Weight Lifting ____________ Gardening _______________
Swimming _______________ Cycling ___________________ Massage _________________
Horseback Riding ________ Dog Training _____________ Fishing __________________
WORK: (8)
__________________________________________________________________________
__________________________________________________________________________
SOCIAL ACTIVITIES: (3)
FRIENDS _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
OTHER __________________________________________________________________
__________________________________________________________________________
RECREATION: (1)
__________________________________________________________________________
__________________________________________________________________________
CODE FOR POINT SYSTEM:
BONUS POINTS: FOOD
No Coffee = 10 Pts 2 Cups or Less = 5 Pts 3 Cups or Less = 2 Pts
Vegetables = 2 Pts Ea.
BONUS POINTS: PERSONAL
Individualized bonus
SELF-IMPROVEMENT:
Hobby: includes working on written meditations, composing tapes, drawing self-images,
diary notes, writing, planning, or tallying weekly scores.
FOOD PLAN:
Assign 1 point per LINE SPACE on 1st five items.
Rank the No Sugar item according to the following:
1 box = 1 dessert 2 boxes = 1/2 dessert
3 boxes = 2 T. or less 4 boxes = No sugar
Rank the Low Salt item according to the following:
1 box = 1 salty food 2 boxes = small salty serving
3 boxes = salt in food 4 boxes = no salt
Rank the Low Fat item according to the following:
1 box = 1 fat food 2 boxes = moderate fatty food
3 boxes = fat in cooking 4 boxes = 5 fat choices as per plan
Assign 1 point for each food choice category done correctly, e.g. milk
PHYSICAL EXERCISE:
Stretch Exercises, One-Minute Exercises: one box per each 5 exercises
Other Exercises, Dog Training, Stairs, Weight Lifting: one box per each 10 minutes
Swimming: One box per each 3 laps
Piano, Gardening, Cycling, Dancing and Walk: One box per each 20 minutes
Fishing, Massage: One box per each hour
WORK:
One point for each 1/2 hour of work
RECREATION:
One point for any recreation, including activities listed above with friends
SELF-IMPROVEMENT(5)
MEDITATION_______ HOBBY______MUSIC______READING_______HELPING______________
Any New Growth in Moderation_____________________________________________________
FOOD PLAN: (G:23) ___LOWFAT ___NO SUGAR ___NO WHITE FLOUR ___OTHER
BEHAVIOR CONTROL: Hunger _ _ _ _ Table _ _ _ _ _ Eating Slowly _ _ _ _ Stop When Not Hungry _ _ _ _
FOOD CONTROL: Water _ _ _ _ _ _ Sugar _ _ _ _ White Flour_ _ _ _ Salt _ _ _ _ Fat _ _ _ _
Milk(2)___ Meat(6)______ Vegetable(B)____ Bread(4)_____ Fat(5)_____ Fruit(3)___ Caffeine___
6 small Meals _________________ Reward for 350 Points___________________________________
NOTES: _______________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PHYSICAL EXERCISE: (G:10) See Instructions about Points for Time Spent
Stretch Exercises__________ 1 Minute Exercise __________ Other Exercise ____________
Piano____________________ Dancing___________________ Singing __________________
Walk ____________________ Weight Lifting ____________ Gardening _______________
Swimming _______________ Cycling ___________________ Massage _________________
Horseback Riding ________ Dog Training _____________ Fishing __________________
WORK: (8)
__________________________________________________________________________
__________________________________________________________________________
SOCIAL ACTIVITIES: (3)
FRIENDS _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
OTHER __________________________________________________________________
__________________________________________________________________________
RECREATION: (1)
__________________________________________________________________________
__________________________________________________________________________
CODE FOR POINT SYSTEM:
BONUS POINTS: FOOD
No Coffee = 10 Pts 2 Cups or Less = 5 Pts 3 Cups or Less = 2 Pts
Vegetables = 2 Pts Ea.
BONUS POINTS: PERSONAL
Individualized bonus
SELF-IMPROVEMENT:
Hobby: includes working on written meditations, composing tapes, drawing self-images,
diary notes, writing, planning, or tallying weekly scores.
FOOD PLAN:
Assign 1 point per LINE SPACE on 1st five items.
Rank the No Sugar item according to the following:
1 box = 1 dessert 2 boxes = 1/2 dessert
3 boxes = 2 T. or less 4 boxes = No sugar
Rank the Low Salt item according to the following:
1 box = 1 salty food 2 boxes = small salty serving
3 boxes = salt in food 4 boxes = no salt
Rank the Low Fat item according to the following:
1 box = 1 fat food 2 boxes = moderate fatty food
3 boxes = fat in cooking 4 boxes = 5 fat choices as per plan
Assign 1 point for each food choice category done correctly, e.g. milk
PHYSICAL EXERCISE:
Stretch Exercises, One-Minute Exercises: one box per each 5 exercises
Other Exercises, Dog Training, Stairs, Weight Lifting: one box per each 10 minutes
Swimming: One box per each 3 laps
Piano, Gardening, Cycling, Dancing and Walk: One box per each 20 minutes
Fishing, Massage: One box per each hour
WORK:
One point for each 1/2 hour of work
RECREATION:
One point for any recreation, including activities listed above with friends
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© Copyright by Nancy Carter, LCSW, ACSW