Vaping E-Cigarette Screening Survey & Goal Plan
This Goal Plan/Contract takes about 5-minutes to complete.
*
1.
What is today's date (month/day/year)?
(Required.)
2.
First and Last Name (Optional)
*
3.
Are you...
(Required.)
Male
Female
Other
*
4.
How old are you?
(Required.)
9 years old or younger
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old
19 years old
20 years old
21 years old
22 years old
23 years old
24 years old
25 years old or older
5.
What sports or physical activities did you play in the last year?
6.
Do you participate in any physical activity for at least 30 minutes four or five times a week? For example, riding a bike, running, walking, swimming, or playing a sport for 30 minutes or more on most days.
Yes
No
7.
Do your friends influence you to participate in regular physical activity?
Yes
No
8.
Do you usually eat a healthy breakfast each morning? For example, cereal and low-fat milk, whole wheat toast, oatmeal, eggs, yogurt or fruit.
Yes
No
9.
Do you usually sleep eight or more hours each night?
Yes
No
10.
Have you ever used an electronic or e-cigarette? For example, a JUUL, e-cig, e-hookah, hookah pen, vape, vape pen or mod.
Yes
No
*
11.
Which of the following do you pledge to avoid or reduce during the next 7 days in order to maintain an active and healthy lifestyle?
(Required.)
Alcohol
Tobacco
E-cigarettes
Marijuana
Non-medical opioids
Other illegal drugs
*
12.
Which
one
of the following healthy habits will you focus on improving during the next 7 days.
(Required.)
Get 8 or more hours sleep each night
Eat a healthy breakfast every day or eat a daily variety of other healthy foods such as fresh fruits and vegetables
Participate in some fun physical activity or sports at least 30 minutes 4-5 days per week
Practice a stress control technique most days a week like yoga, meditation, prayer or walking in nature.
Other (please specify)
*
13.
From the healthy habit you identified, now write a
specific, measurable and attainable healthy habit goal
you will achieve over the next 7 days. For example, playing tennis is measurable but getting more exercise is not, and eating more fruits and vegetables is measurable but eating healthier is not.
(Required.)
*
14.
Now, write an
exact amount (quantity) of that one habit
you just listed above which you will do each time you do it. For example, 30 minutes each time you play tennis, or 1 more serving of fruits and vegetables each day.
(Required.)
*
15.
Last,
list an exact frequency of that same habit
you will do during the next week. For example, 4 days a week, Monday-Thursday, or each day of the week.
(Required.)
*
16.
In addition to yourself, who else will sign this goal plan to make it an official contract between you and them?
(Required.)
Teacher
Mom or dad
Grandmother or grandfather
Aunt or uncle
Older brother or sister
Trusted and supportive friend
Other (please specify)
*
17.
Where will you post your goal plan/contract so you can see it every day and be reminded to monitor your health habits? Choose one.
(Required.)
Bedroom wall or mirror
Bathroom mirror
Refrigerator door
TV or computer
Other (please specify)
18.
Congratulations! You have successfully completed a Prevention Plus Wellness program goal plan.
· Print out a copy of your goal plan so you can sign and date it and have the person you identified co-sign it.
· Don't forget to post your goal plan where you can see it every day and check-off each day you reach a goal.
· At the end of your 7-day goal plan return to this site and write another goal plan to continue to make small changes to feel and look better.
· Reward yourself with small things you enjoy like magazines, music, books, watching a movie, playing and instrument, or doing art, for achieving one of your wellness goals, or avoiding alcohol, tobacco, e-cigarettes or illegal drug use.
Now rate the goal plan on the 5-star scale below.
1 star
2 stars
3 stars
4 stars
5 stars
19.
After you print out this goal plan
, circle a response on the calendar below each day during the next 7 days to track your goal success. Then, total the number of days you reached a wellness goal.
Do NOT Answer This Now.
Day 1 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 2 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 3 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 4 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 5 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 6 Goal Success: 1: Yes 2: No 3: No goal set for today
Day 7 Goal Success: 1: Yes 2: No 3: No goal set for today
Week's Total Success Days (Number of "Yeses" Above) =
20.
Now, print out your goal plan and post it so you’ll see it every day for the next 7 days.
